Asthma in Virginia

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					      Asthma In Virginia
 A Comprehensive Data Report, 2006




    Virginia Department of Health
Division of Chronic Disease Prevention and Control
          Virginia Asthma Control Project
 Asthma in Virginia, 2006

ACKNOWLEDGEMENTS


Office of Family Health Services
David Suttle, MD, Director


Division of Chronic Disease Prevention and Control
Ramona Dawn Schaeffer, MSEd, CHES, Director


Asthma Control Project
Carol Stanley, MS
Asthma Control Project Manager


Prepared by:
Rebeka Sultana, MPH, Asthma Epidemiologist
Virginia Asthma Control Project


Centers for Disease Control and Prevention
Marissa Scalia, MPH
Asthma Program Epidemiologist
National Center for Environmental Health
Centers for Disease Control and Prevention
 Asthma in Virginia, 2006

Reviewers:
Gail C. Jennings, PhD
Epidemiologist
Div. Chronic Disease Prevention & Control (DCDPC)
Virginia Department of Health

Henry J. Carretta, MPH
Member, Surveillance and Evaluation Workgroup
Virginia Asthma Coalition

Myra Shook, MPH
Chronic Disease Program Supervisor
Div. Chronic Disease Prevention & Control (DCDPC)
Virginia Department of Health



For More information or to obtain additional copies of this report contact:
Virginia Asthma Control Project
Div. Chronic Disease Prevention & Control (DCDPC)
Virginia Department of Health
109 Governor Street, 10th Floor
Richmond, Virginia 23219
(804) 864-7877

Report is also available on the VDH Chronic Disease Prevention and Control website:
http://www.vahealth.org/cdpc/asthma/


Suggested Citation: Asthma in Virginia: A Comprehensive Data Report, 2006. Division of
Chronic Disease Prevention and Control (DCDPC). Virginia Department of Health. Richmond,
VA. October 2006.



This report supported by Cooperative Agreement Number U59/CCU324181 from the Centers for
Disease Control and Prevention (CDC). Its contents are solely the responsibility of the author
and do not necessarily represent the official views of CDC.
  Asthma in Virginia, 2006

                                                         TABLE OF CONTENTS
LIST of TABLES ......................................................................................................................................... ii
LIST of FIGURES ...................................................................................................................................... iii
EVALUATION FORM …………………………………………………………………………………..vi
EXECUTIVE SUMMARY ......................................................................................................................... 1
INTRODUCTION ....................................................................................................................................... 3
VIRGINIA ASTHMA CONTROL PROJECT......................................................................................... 5
VIRGINIA ASTHMA COALITIONS....................................................................................................... 5
VIRGINIA DEMOGRAPHICS ................................................................................................................. 6
ASTHMA PREVALENCE ......................................................................................................................... 7
ADULT ASTHMA PREVALENCE .......................................................................................................... 8
ASTHMA MANAGEMENT AND CONTROL...................................................................................... 18
CHILDHOOD ASTHMA PREVALENCE............................................................................................. 35
ASTHMA INPATIENT HOSPITALIZATIONS ................................................................................... 37
COST OF ASTHMA IN VIRGINIA........................................................................................................ 49
ASTHMA DEATHS IN VIRGINIA......................................................................................................... 55
ASTHMA IN SCHOOL ............................................................................................................................ 61
WORK-RELATED ASTHMA ................................................................................................................. 63
CONCLUSIONS ........................................................................................................................................ 64
REFERENCES .......................................................................................................................................... 65
ACRONYMS.............................................................................................................................................. 68
APPENDIX A. TECHNICAL NOTES .................................................................................................... 69
APPENDIX B. DETAILED DATA TABLES ......................................................................................... 72
APPENDIX C. SOURCES OF DATA ..................................................................................................... 86
APPENDIX D. HEALTHY PEOPLE 2010 OBJECTIVES FOR ASTHMA ...................................... 89
APPENDIX E. VIRGINIA BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM,
ASTHMA QUESTIONS ........................................................................................................................... 90




                                                                                                                                                          i
  Asthma in Virginia, 2006

                                                                       LIST OF TABLES
Table 1. Population Distribution of Virginia and U.S., 2004 ......................................................................................... 6
Table 2. Current and Lifetime Asthma Among Adults, Virginia and U.S. 2002-2004................................................... 8
Table 3. Annual Asthma Hospital Discharges and Rates (per 10,000), Virginia, 1999-2004 .................................... 38
Table 4. Asthma Hospital Discharge Rates (per 10,000) Virginia, 2004 and Healthy People 2010 Objectives, by Age
.................................................................................................................................................................................... 40
Table 5. Asthma Hospitalization Charges, by Primary Payor, Virginia, 2004 ............................................................ 49
Table 6. Length of Stay (LOS) and Charges for Asthma Hospitalization, Virginia, 1999-2004.................................. 50
Table 7. Asthma Mortality Rates* (per 1,000,000) Virginia, 1999-2004 (combined) and Healthy People 2010
Objectives, by Age ...................................................................................................................................................... 60
Table 8. Percent of School-Based Asthma Management Activities Among Public Schools, Grades 6, and Higher,
Virginia, 2002 and 2004.............................................................................................................................................. 62
Table 9. Current Asthma Among Adults, by Demographic Subgroup, Virginia and U.S., 2004................................. 72
Table 10. Lifetime Asthma Among Adults, by Demographic Subgroup, Virginia and U.S., 2004 .............................. 73
Table 11. Percentage of Adults with Behavioral Risk Factors by Current Asthma Status, Virginia, 2004 ................. 74
Table 12. Current Asthma Among Adults, by Health District, Virginia, 2004 ............................................................. 75
Table 13. Asthma Management and Control Among Adults with Current Asthma, Virginia, 2003-2004 (combined) 76
Table 14. Asthma Management and Control Among Adults with Current Asthma, Virginia, 2003-2004 (combined) 77
Table 15. Asthma Management and Control Among Adults with Current Asthma, Virginia, 2003-2004 (combined) 78
Table 16. Asthma Hospital Discharge Rates*(per 10,000) by Age, Virginia, 1999-2004 ........................................... 79
Table 17. Asthma Hospital Discharge Rates*(per 10,000) by Sex and Race/Ethnicity, Virginia, 1999-2004 ............ 79
Table 18. Asthma Hospitalizations by Month of Admission, Virginia, 2002-2004 ...................................................... 79
Table 19. Asthma Hospital Discharge Rates*(per 10,000) by Health District, Virginia, 2002-2004 ........................... 80
Table 20. Asthma Hospitalizations, Average Length of Stay (LOS), Average Charges (dollars) per Asthma
Hospitalization, and Total Asthma Hospitalization Charges (dollars) by Age, Sex, and Race/Ethnicity, Virginia, 2004
.................................................................................................................................................................................... 81
Table 21. Average Charges per Asthma Hospitalization by Health District, Virginia, 1999-2004.............................. 82
Table 22. Average Length of Stay (LOS) for Asthma Hospitalization by Health District, Virginia, 1999-2004........... 83
Table 23. Asthma Mortality Rates*(per 1,000,000) Virginia, 1999-2004 .................................................................... 84
Table 24. Asthma Mortality Rates*(per 1,000,000) by Age, Sex, and Race, Virginia, 1999-2004 (combined).......... 84
Table 25. Asthma Mortality Rates* (per 1,000,000) by Sex and Race Virginia, 1999-2004 (combined) ................... 84
Table 26. Asthma Deaths by Health Districts, Virginia, 1999-2004 (combined) ........................................................ 85




                                                                                                                                                                                     ii
  Asthma in Virginia, 2006

                                                                      LIST OF FIGURES
Figure 1. Current Asthma Among Adults, by Age, Virginia and U.S., 2004 ................................................................. 9
Figure 2. Current Asthma Among Adults, by Sex, Virginia and U.S., 2004 ................................................................. 9
Figure 3. Current Asthma Among Adults, by Race and Ethnicity, Virginia and U.S., 2004 ....................................... 10
Figure 4. Current Asthma Among Adults, by Income, Virginia and U.S., 2004.......................................................... 10
Figure 5. Current Asthma Among Adults, by Education, Virginia and U.S., 2004...................................................... 11
Figure 6. Smoking Status Among Adults, by Current Asthma Status, Virginia, 2004 ................................................ 12
Figure 7. General Health Status Among Adults, by Current Asthma Status, Virginia, 2004 ...................................... 13
Figure 8. Weight Status Among Adults, by Current Asthma Status, Virginia, 2004 ................................................... 14
Figure 9. Influenza Vaccination Status Among Adults, by Current Asthma Status, Virginia, 2004............................ 15
Figure 10. Geographic Density Status Among Adults, by Current Asthma Status, Virginia, 2004 ............................ 16
Figure 11. Health Insurance Status Among Adults, by Current Asthma Status, Virginia, 2004................................. 16
Figure 12. Current Asthma Among Adults, by Health District, Virginia, 2004 ............................................................ 17
Figure 13. Asthma Attack Among Adults with Current Asthma in the Past 12 Months, Virginia, 2003-2004............. 18
Figure 14. Asthma Attack Among Adults with Current Asthma in the Past 12 Months, by Age, Virginia, 2003-2004 19
Figure 15. Asthma Attack Among Adults with Current Asthma in the Past 12 Months, by Income, Virginia, 2003-
2004 ............................................................................................................................................................................ 19
Figure 16. Activity Limitations Among Adults with Current Asthma in the Past 12 Months, Virginia, 2003-2004 ...... 20
Figure 17. Activity Limitations Among Adults with Current Asthma in the Past 12 Months, by Education, Virginia,
2003-2004................................................................................................................................................................... 21
Figure 18. Activity Limitations Among Adults with Current Asthma in the Past 12 Months, by Income, Virginia, 2003-
2004 ............................................................................................................................................................................ 21
Figure 19. Sleeping Difficulty Among Adults with Current Asthma in the Past 30 Days, Virginia, 2003-2004........... 22
Figure 20. Sleeping Difficulty Among Adults with Current Asthma in the Past 30 Days, by Age, Virginia, 2003-2004
.................................................................................................................................................................................... 23
Figure 21. Sleeping Difficulty Among Adults with Current Asthma in the Past 30 Days, by Income, Virginia, 2003-
2004 ............................................................................................................................................................................ 23
Figure 22. Asthma Symptoms Among Adults with Current Asthma in the Past 30 Days, Virginia, 2003-2004 ......... 24
Figure 23. Asthma Symptoms Among Adults with Current Asthma in the Past 30 Days, by Education, Virginia,
2003-2004................................................................................................................................................................... 25
Figure 24. Asthma Symptoms Among Adults with Current Asthma in the Past 30 Days, by Income, Virginia, 2003-
2004 ............................................................................................................................................................................ 25
Figure 25. Health Care Visits Among Adults with Current Asthma in the Past 12 Months, Virginia, 2003-2004 ....... 26
Figure 26. Health Care Visits Among Adults with Current Asthma in the Past 12 Months, by Age, Virginia, 2003-
2004 ............................................................................................................................................................................ 26
Figure 27. Health Care Visits Among Adults with Current Asthma in the Past 12 Months, by Income, Virginia, 2003-
2004 ............................................................................................................................................................................ 27
Figure 28. Health Care Visits Among Adults with Current Asthma in the Past 12 Months, by Education, Virginia,
2003-2004................................................................................................................................................................... 27




                                                                                                                                                                                    iii
  Asthma in Virginia, 2006

Figure 29. Emergency Department/ Urgent Care Center Visits Among Adults with Current Asthma in the Past 12
Months, Virginia, 2003-2004....................................................................................................................................... 28
Figure 30. Emergency Department/ Urgent Care Center Visits Among Adults with Current Asthma in the Past 12
Months, by Age, Virginia, 2003-2004 ......................................................................................................................... 29
Figure 31. Emergency Department/ Urgent Care Center Visits Among Adults with Current Asthma in the Past 12
Months, by Income, Virginia, 2003-2004 .................................................................................................................... 29
Figure 32. Routine Check-up Among Adults with Current Asthma in the Past 12 Months, Virginia, 2003-2004 ....... 30
Figure 33. Routine Check-up Among Adults with Current Asthma in the past 12 Months, by Age, Virginia, 2003-
2004 ............................................................................................................................................................................ 31
Figure 34. Routine Check-up Among Adults with Current Asthma in the Past 12 Months, by Education, Virginia,
2003-2004................................................................................................................................................................... 31
Figure 35. Asthma Medication Usage Among Adults with Current Asthma in the Past 30 Days, Virginia, 2003-2004
.................................................................................................................................................................................... 32
Figure 36. Asthma Medication Usage Among Adults with Current Asthma in the Past 30 Days, by Age, Virginia,
2003-2004................................................................................................................................................................... 33
Figure 37. Asthma Medication Usage Among Adults with Current Asthma in the Past 30 Days, by Education,
Virginia, 2003-2004..................................................................................................................................................... 33
Figure 38. Reported Age at First Diagnosis of Asthma Among Adults with Current Asthma, Virginia, 2003-2004 ... 34
Figure 39.Children/Youth, (Ages 0-17), Affected by Asthma During the Past 12 Months, Virginia and U.S., 2003 .. 36
Figure 40. Impact of Children’s (Ages 0-17) Asthma on Family, Among Children with Asthma, Virginia and U.S.,
2003 ............................................................................................................................................................................ 36
Figure 41. Asthma Hospital Discharge Rates* (per 10,000) Virginia, 1999-2004 ...................................................... 38
Figure 42. Asthma Hospital Discharge Rates* (per 10,000) by Age, Virginia, 1999-2004......................................... 39
Figure 43. Asthma Hospital Discharge Rates* (per 10,000) by Sex, Virginia, 1999-2004 ......................................... 41
Figure 44. Asthma Hospital Discharge Rates* (per 10,000) by Sex and Age, Virginia, 2004.................................... 42
Figure 45. Asthma Hospital Discharge Rates* (per 10,000) by Race/Ethnicity, Virginia, 1999- 2004 ....................... 43
Figure 46. Asthma Hospital Discharge Rates* (per 10,000) by Age and Race/Ethnicity, Virginia, 1999- 2004
(Combined) ................................................................................................................................................................. 44
Figure 47. Asthma Hospitalizations by Month of Admission, Virginia, 2004 .............................................................. 45
Figure 48. Asthma Hospital Discharge Rates* (per 10,000) by Health District, Virginia, 2002 .................................. 46
Figure 49. Asthma Hospital Discharge Rates* (per 10,000) by Health District, Virginia, 2003 .................................. 47
Figure 50. Asthma Hospital Discharge Rates* (per 10,000) by Health District, Virginia, 2004 .................................. 48
Figure 51. Average Charges per Asthma Hospitalization by Age, Virginia, 1999-2004............................................. 51
Figure 52. Average Charges per Asthma Hospitalization by Sex, Virginia, 1999-2004 ............................................. 51
Figure 53. Average Charges per Asthma Hospitalization by Health District, Virginia, 2004 ...................................... 52
Figure 54. Average Length of Stay for Asthma Hospitalization by Age, Virginia, 1999-2004 .................................... 53
Figure 55. Average Length of Stay for Asthma Hospitalization by Health District, Virginia, 2004 ............................. 54
Figure 56. Asthma Mortality Rates* (per 1,000,000) Virginia, 1999-2004.................................................................. 56
Figure 57. Asthma Mortality Rates* (per 1,000,000) by Age, Virginia, 1999-2004 (combined) ................................ 57
Figure 58. Asthma Mortality Rates* (per 1,000,000) by Sex, Virginia, 1999- 2004.................................................... 58



                                                                                                                                                                                    iv
 Asthma in Virginia, 2006

Figure 59. Asthma Mortality Rates* (per 1,000,000) by Race, Virginia, 1999- 2004 ................................................. 58
Figure 60. Asthma Mortality Rates* (per 1,000,000) by Sex and Age, Virginia, 1999-2004 ...................................... 59
Figure 61. Asthma Mortality Rates* (per 1,000,000) by Race and Age, Virginia, 1999-2004 .................................... 59




                                                                                                                                   v
 Asthma in Virginia, 2006

Asthma in Virginia, Comprehensive Data Report, 2006
Evaluation Form
In order to help the Virginia Department of Health (VDH) evaluate the usefulness of the 2006
data report on asthma, please answer the questions that follow. Your responses will enable the
VDH to identify opportunities for improvement for future comprehensive data reports on the
burden of asthma in Virginia. Please submit your evaluation form to the fax number or mailing
address listed at the end of the form. Responses will be aggregated and reviewed for the future
edition of the data report. Thank you for taking the time to provide us with your feedback.

1. Type of organization or group you represent: (check all that apply):
        Local health district                           Medical or health professional
        State or local coalition                     association (e.g. AMA, AAFP)
        Community health organization                   Faith-based organization
        Hospital, clinic, practice, or other medical    Health insurance organization
       facility                                         Private business (non-medical)
        Local or state government                       Person with asthma, family
        Federal agency (e.g. CDC)                    member, or acquaintance (skip to #5 if
        Academic institution: college, university,   this is your only category selected))
       school of public health                          Pharmacy
        State or national partner (e.g. ALA,             Pharmaceutical Company
       ALAV, Department of Education)                    Public or private school
        Media, marketing group                           Certified Asthma Educator
                                                        Other: _______________________

     2. Name of organization or group (optional): __________________________________

     3. What is your role in the organization? (Check all that apply)
         Health care provider (doctor, nurse,
         Pharmacist)
         Administrator
          Educator
          Epidemiologist, data analyst,
        researcher
          Local or state govt. official
         Community organizer or leader
          Supervisor
          Legislator (state, local)
         School Nurse
          Other:




                                                                                              vi
   Asthma in Virginia, 2006

4. Types of populations served by your organization(s): (check all that apply):

    General population
    Males
    Females
    American Indians or Alaska Natives
    Asian Americans or Hawaiians/Pacific Islanders
    Blacks or African Americans
    Whites
    Hispanics/Latinos
    Youth, under 18
    Healthcare industry: providers/insurers
    Persons with disabilities
    Gay, Lesbian, Bisexual & Transgender
    Low income/ Low socio-economic status populations
    Rural residents
    Urban residents
    Other________________________


5. Is this report a valuable resource tool for you or your organization?
    Yes           No (If No, skip to Q6)
        a.     If YES, how does (or will) your organization use the report? (check all that
            apply)
    To target asthma education to the public
    To raise awareness among health care providers regarding the burden of asthma in
      their communities
    To include key data elements/information into grant proposals
     To make the case to local businesses to donate money to our organization to help
      control asthma
    To include key data elements/information into written and verbal communications to
      regulatory/legislative and/or lobbying entities to make the case for better asthma
      control policies (clean indoor air, better regulations in public housing, etc.)
    To advocate to school system leaders to strengthen clinical support in the schools
      to help students with asthma manage their condition better
    To make the case to an employer to make their workplace environment more
      conducive to preventing asthma complications among their employees who have
      asthma
    Other


6. Which geographically separated data sets are most useful to you? (check only one)
    Local (my city or county or health district)
    Statewide




                                                                                        vii
     Asthma in Virginia, 2006

7. How could the report be modified to be more useful to your organization?




8. Please rate the usefulness of each section: 1=very useful, 2=somewhat useful,
  3=less useful, 4=not at all useful. Mark only those sections that you reviewed.
 ___ Executive Summary                                 ___ Costs of Asthma in Virginia
 ___ Introduction – Asthma Control Project             ___ Asthma Deaths in Virginia
 ___ Virginia Demographics                             ___ Asthma in Schools
 ___ Asthma Prevalence                                 ___ Work-Related Asthma
 ___ Childhood Asthma Prevalence                       ___ Conclusions
 ___ Asthma Inpatient Hospitalizations                 ___ Appendices



9. Please list other organizations (names, phone numbers) that you think could use the
   report.



10. Other comments (re: format, layout).



FAX or MAIL your completed form to:
                                            Asthma Control Program Manager
                                            Virginia Department of Health
                                            Chronic Disease Prevention & Control
                                            109 Governor Street, 10th Floor
                                            P. O. Box 2448
                                            Richmond, VA 23218
                                           Telephone: (804) 864-7877
                                           Fax: (804) 864-7880

                       Thank you for reviewing the report.




                                                                                     viii
 Asthma in Virginia, 2006

Executive Summary
Asthma is a chronic inflammatory disease of the airways characterized by repeated and
distressing episodes of wheezing, shortness of breath, chest tightness, and nighttime or early
morning coughing. Asthma can be difficult to diagnose and to differentiate from other respiratory
illnesses. This report compares Virginia to United States 2004 data and Healthy People 2010
Objectives. In addition, Asthma in Virginia data report provides the reader with data about
prevalence, hospitalization, mortality, and cost associated with asthma.

Highlights of asthma burden in Virginia include:
Prevalence, 2004

Estimates from the Behavioral Risk Factor Surveillance System (BRFSS)
   ♦ About 13.3 percent (748,668) of adults in Virginia have had asthma at some point in their
      lifetime.

   ♦ About 7.3 percent (412,370) of adults in Virginia reported having current asthma. This
     estimate is lower than the national estimate of 8.1 percent, with females in Virginia having
     twice the current asthma prevalence than males (10% versus 4.5%).

   ♦ The current asthma prevalence rate was higher among adults who are multiracial, obese,
     less educated, and of low income.

Asthma Management and Control, 2003-2004

Estimates from the BRFSS
   ♦ About 69 percent of adults with current asthma experienced asthma symptoms in the past
      30 days. Adults without health insurance experienced more asthma symptoms than
      adults with health insurance (81.8% versus 66.4%).

   ♦ Among adults with current asthma, 21 percent visited an emergency department (ED)
     due to asthma, at least once in the past 12 months. ED visits were more likely in younger
     adults than in older age groups (25.5% in 18-24 year olds versus 14.3% in those 65 and
     older).

   ♦ Approximately 42 percent of adults with current asthma reported that their asthma had
     been diagnosed when they were 10 years old or younger.

Asthma Inpatient Hospitalizations, 2004

Results from the Virginia Health Information Patient Level Data (VHI)
  ♦ Asthma hospitalizations have declined over the past 6 years in Virginia. In 2004, there
      were 9,460 asthma hospitalizations among Virginia residents with a rate (age-adjusted) of
      12.9 per 10,000 population compared to 15.9 per 10,000 population in 1999.



                                                                                                1
 Asthma in Virginia, 2006

   ♦ Children less than 5 years of age had the highest asthma hospitalization rate (36.6 per
     10,000 population), followed by the 65 years and older group, with a rate of 23.5 per
     10,000 population.

   ♦ Female Virginians had higher asthma hospitalization rates than males (15.2 per 10,000
     population versus 10.2 per 10,000 population) and the rate among Blacks was more than
     two times higher than the rate among the white population (24.1 per 10,000 population
     versus 9.5 per 10,000 population).

Cost of Asthma, 2004

Results from the VHI
  ♦ The average charge for an asthma hospitalization was $10,211, with an average length of
      stay of 3.6 days. The average charge per asthma hospitalization increased with age.

   ♦ Females had consistently higher average charges per asthma hospitalization than males.

   ♦ Medicare was the primary payor for 40 percent of all asthma hospitalization charges in
     Virginia followed by private insurance (34%).

Asthma Deaths, 1999-2004

Results from the Virginia Department of Health (VDH), Division of Health Statistics
  ♦ There were 680 asthma deaths with an average of 113 per year during 1999-2004, for a
      rate of 16.2 per 1,000,000.

   ♦ Asthma mortality increased with age. Adults, 65 years of age and older, had the highest
     mortality rate at 62.8 per 1,000,000.

   ♦ More females and blacks died from asthma than males and whites.

Asthma in Schools, 2004

Results from the School Health Education Profile (SHEP) Survey
  ♦ Approximately 90 percent of Virginia public schools conducted 4 out of ten activities
      related to asthma management, which is an increase from two in 10 in 2002.

   ♦ Sixty percent of schools employ a full-time registered nurse.

The goals of the Virginia Asthma Control Project (VACP) are to: 1) reduce the prevalence,
morbidity, and mortality due to asthma; 2) improve asthma care; and 3) decrease health
disparities in Virginia through health education, policy change, and selected interventions. The
following Asthma Surveillance report will be a useful tool to disseminate relevant information,
inform key stakeholders about asthma in Virginia, and identify areas in need of program
development and policy change.


                                                                                              2
 Asthma in Virginia, 2006

Introduction
Asthma is a chronic inflammatory disease of the airways characterized by repeated and
distressing episodes of wheezing, shortness of breath, chest tightness, and nighttime or early
morning coughing. Asthma can be difficult to diagnose and to differentiate from other respiratory
illnesses. The cause of the disease is unknown, as is a cure, but studies show that asthma can
be well managed and controlled. [1]

According to the Asthma and Allergy Foundation of America (AAFA), asthma is classified into
two categories: [2]
   ♦ Allergic asthma - The common form of asthma; also referred to as extrinsic asthma.
      Attacks are characterized by symptoms that are associated with exposure to allergens,
      like environmental pollen, dust mites, pet dander, and mold.

   ♦ Non-allergic asthma – This form of asthma referred to as intrinsic asthma, results from
     other factors not related to an allergic response, such as sinus infection, smoke, stress,
     cold air, and physical activity.

According to the National Heart, Lung, and Blood Institute’s (NHLBI) National Asthma Education
and Prevention Program (NAEPP), asthma can be categorized in terms of severity based on
patient-reported symptoms and clinical features before treatment: [3]
    ♦ Mild Intermittent (Step 1) - Daytime symptoms occur two or fewer times per week and
       nighttime symptoms occur two or fewer times a month. Pulmonary function test results
       are normal.
    ♦ Mild Persistent (Step 2) - Daytime symptoms occur two or more times per week and
       nighttime symptoms occur two or more times a month, but pulmonary function is normal.
    ♦ Moderate Persistent Asthma (Step 3) - Daytime symptoms occur daily, nighttime
       symptoms occur one or more times a week, or pulmonary functioning is reduced to 60
       percent to 80 percent of normal.
    ♦ Severe Persistent Asthma (Step 4) - Daytime symptoms occur on a continual basis and
       night symptoms are also frequent, and pulmonary function may be less than 60 percent of
       normal. This the most severe form of asthma.

Asthma is a major public health problem of increasing concern in the United States both for
adults and children. From 1980 to 1996, asthma prevalence among children increased by an
average of 4.3 percent per year, from 3.6 percent to 6.2 percent. Asthma accounts for 14 million
lost days of school annually. Asthma is the third-ranking cause of hospitalization among those
younger than 15 years of age. The estimated cost of treating asthma in those younger than 18
years of age is $3.2 billion per year. [1]

 According to Centers for Disease Control and Prevention (CDC), asthma death rates are
leveling off and asthma hospitalization rates are declining, but the impact of asthma on health,
quality of life, and the economy remain critical. The burden of the disease is disproportionately
distributed across the population and geographic regions. Females, children, the poor, and
minority populations are affected more by asthma. Blacks continue to have higher rates of
hospitalization and death from asthma than whites. [1]


                                                                                               3
 Asthma in Virginia, 2006

According to data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS), an
estimated 18 million (8.1%) adults have current asthma in the United States. [4] In 2004, in
Virginia, 7.3 percent of adults reported having current asthma. There were 9,460 hospital
discharges with a rate of 12.9 (age-adjusted) per 10,000 and total charges for asthma
hospitalization were $96 million, with an average charge of $10,211 in 2004. During the period of
1999-2004, in Virginia, there were 680 asthma deaths, with an average of 113 per year, for a
rate of 16.2 per million.

Asthma morbidity and mortality in the United States are mostly due to less than optimal medical
management by physicians, poor patient adherence to medical recommendations, or lack of
access to the medical care system. For example, hospitalizations due to asthma are generally
preventable if patients receive appropriate treatment and follow recommendations to reduce
enviornmental exposures and adopt other asthma self-management practices. Medical
management of asthma can be complex and it often requires asthmatic patients to follow
complicated treatment regimens and implement difficult behavioral changes. However, good
medical and patient self-management usually result in improved quality of life and reduced
symptomology. Further monitoring and treatment are needed to maintain control once a patient’s
asthma is under control. [5]

The NAEPP Guidelines for the Diagnosis and Management of Asthma (NHLBI 1997), and the
2002 Update (NHLBI 2002), are considered as essential for quality asthma care practices. To
implement these guidelines effectively and to assist physicians, Key Clinical Activities for Quality
Asthma Care (Morbidity and Mortality Weekly Report, Vol.52/No.RR-6, March 28, 2003) was
published as a collaborative effort between CDC and the NAEPP. [6] The four effective
components of asthma management described in the report are: assessment and monitoring,
controlling triggers contributing to asthma severity, appropriate medications, and patient
education. These essential components are associated with 10 key clinical activities, which are
listed below:

   ♦   Establish asthma diagnosis,
   ♦   Classify severity of asthma,
   ♦   Schedule routine follow-up care,
   ♦   Assess for referral to specialty care,
   ♦   Recommend measures to control asthma triggers,
   ♦   Treat or prevent comorbid conditions,
   ♦   Prescribe medications according to severity,
   ♦   Monitor use of β2-agonist drugs,
   ♦   Develop a written asthma management plan,
   ♦   Provide routine education on patient self-management.

The components of asthma management guidelines and the 10 key clinical activities for quality
asthma care put forward direction for health care managers and planners in making
assessments needed to ensure quality health care for people with asthma. [6]




                                                                                                  4
 Asthma in Virginia, 2006

Virginia Asthma Control Project
In 2001, the Virginia Asthma Control Project (VACP) was established by the Virginia Department
of Health (VDH) to reduce the burden of asthma statewide. The VACP is awarded by CDC and
is governed by VDH’s Division of Chronic Disease Prevention and Control (DCDPC). The project
focuses on asthma from a public health perspective. The mission of VACP is to improve the
health of all Virginians by decreasing the impact of asthma through expanded and improved
services. VACP goals include: [7]

   ♦ Increase surveillance on an ongoing basis to determine the prevalence and burden of
     asthma,

   ♦ Monitor progress and evaluate interventions,

   ♦ Decrease asthma hospitalizations,

   ♦ Partner with coalitions, healthcare providers, and other stakeholders to plan and
     implement interventions to improve asthma education and management,

   ♦ Provide current asthma information to policymakers and other community partners to
     support policy changes directed at decreasing the burden of asthma,

   ♦ Support interventions that improve the quality and standards of asthma treatment and
     management based on the NHLBI guidelines.

Virginia Asthma Coalitions
The Virginia Asthma Coalition (VAC) is a statewide group that was established through
cooperation between VDH, the American Lung Association of Virginia (ALAV), and the Virginia
Department of Education (VDOE) to address asthma in Virginia. The VAC presents an
opportunity for people to exchange and share views on ways to improve the quality of asthma
care in Virginia. VAC members consist of physicians, nurses, parents, health care providers,
governmental agencies, and respiratory therapists. The goal of VAC is to reduce illness and
death due to asthma among Virginia citizens. [8] There are also seven local asthma coalitions
that have been formed in the Commonwealth of Virginia undertaking a number of agendas
including educational programs for the staff and students of public schools, asthma camps for
children with asthma, development of statewide asthma action plans for school nurses, and
education for public housing residents with asthma. The local asthma coalitions (LAC) active in
Central Virginia, Fredericksburg, Greater Roanoke Valley, Norfolk, Northern Virginia, Price
William Health Districts, and Tazewell County.

This document is the first comprehensive asthma data report in Virginia and represents
information compiled from different available data sources. It also provides a picture of asthma
burden in Virginia. This report may be utilized to direct asthma interventions and policies, to
evaluate control strategies, to track trends over time, and to facilitate progress towards
enhancing healthier lives of all Virginians with asthma.


                                                                                              5
    Asthma in Virginia, 2006

Virginia Demographics
According to the 2000 U.S. Census, Virginia was the 12th most populated state, with 7,078,515
residents. More than three–quarters of the state’s population live in metropolitan areas. There
are 95 counties and 39 independent cities in Virginia. The areas are clustered into 35 health
districts1 and five health-planning regions. Table 1 presents the population distribution of Virginia
and the United States.

                       Table 1. Population Distribution of Virginia and U.S., 2004
                                                                               Virginia                  USA
    Population, 2004 estimate                                                          7,459,827 293,655,404
    Population, percent change, April 1, 2000 to July 1, 2004                             5.4%           4.3%
    Persons under 5 years old, percent, 2004                                              6.9%           7.0%
    Persons under 18 years old, percent, 2004                                            25.0%          26.0%
    Persons 65 years old and over, percent, 2004                                         11.1%          12.0%
    Female persons, percent, 2004                                                        51.2%          51.1%
    White persons, percent, 2004 (a)2                                                    72.6%          75.6%
    Black or African American persons, percent, 2004 (a)                                 19.3%          12.2%
    American Indian and Alaska Native persons, percent, 2004 (a)                          0.2%           0.8%
    Asian persons, percent, 2004 (a)                                                      4.5%           4.2%
    Native Hawaiian and Other Pacific Islander, percent, 2004 (a)                         0.1%           0.1%
    Persons reporting some other race, percent, 2004 (a)                                  1.6%           5.2%
    White persons, not of Hispanic/Latino origin, percent, 2004                          69.0%          77.0%
    Persons reporting two or more races, percent, 2004                                    1.6%           1.9%
    Persons of Hispanic or Latino origin, percent, 2004 (b)3                              5.8%          14.2%
    Language other than English spoken at home, percent, age 5+, 2004                    12.8%          18.7%
    High school graduates, percent of persons age 25+, 2004                              84.9%          83.9%
    Bachelor's degree or higher, percent of persons age 25+, 2004                        32.7%          27.0%
    Persons below poverty, percent, 2004                                                  9.5%          13.1%
Source: U.S. Census Bureau, 2004 American Community Survey.


1
  Hanover Health District, located in the central region of the state, has been renamed Chickahominy Health District,
as of July 2006.
2
  Includes persons reporting only one race.
3
  Hispanic may be of any race.



                                                                                                                   6
 Asthma in Virginia, 2006

Asthma Prevalence
Prevalence data are an essential element of asthma surveillance in Virginia. This data provide
estimates of the number of people with asthma and identify populations with asthma by age,
sex, race, and other demographic factors. Data also provide guidance in the development of
interventions to prevent, manage, and control the disease. Prevalence data can be employed to
monitor asthma trends over time in the population. This information is an important part of
understanding the asthma burden in Virginia and identifies the subpopulations that are
disproportionately affected by the disease. Measuring asthma prevalence can be difficult
because it is a disease characterized by intermittent symptoms and varying degrees of severity.

Asthma prevalence is usually estimated from survey data. Virginia BRFSS is the main source of
estimates in asthma prevalence. BRFSS is a state-based, random-digit-dialed survey of the non-
institutionalized U.S. population, aged 18 years and older, conducted by CDC. BRFSS data are
used to track and monitor the prevalence of chronic diseases and high-risk health behaviors
among adults. It also evaluates progress on decreasing high-risk behaviors, increasing
awareness of chronic diseases, and increasing use of preventive health services. Virginia has
participated in the BRFSS since 1989. During 2000, two core asthma questions were included in
the BRFSS questionnaire to systematically collect data on asthma prevalence among adults in
all participating states and territories. Responses from these questions provide data on current
and lifetime asthma in adults. In 2003, questions on adult asthma history and childhood asthma
were added as optional modules in Virginia. Information on childhood asthma is based on adult
responses.

This part of the report provides data from the 2002-2004 Virginia BRFSS. Data on current and
lifetime asthma among adults, asthma management and control among adults with current
asthma, and childhood asthma, are included in this report. Data was analyzed by the year of
survey, age, sex, race/ethnicity, income, and education to be able to present asthma prevalence
by the same demographic factors. Additional data on factors like smoking, general health status,
influenza vaccination, weight, health insurance, and geographic density are also included for
comparison between adults with and without current asthma. In this report, data on adult asthma
history are aggregated, unless otherwise specified, from 2003 through 2004, to obtain the
statistically reliable rates.

Current asthma was defined as answering yes to two questions, “Have you ever been told by a
doctor, nurse, or other health professional that you had asthma?” followed by response to the
subsequent question, “Do you still have asthma?” The rate for current asthma prevalence was
computed by dividing the number of adults who reported current asthma by the number of adults
who responded and completed the survey. Lifetime asthma was defined as answering yes to the
question, “Have you ever been told by a doctor, nurse, or other health professional that you had
asthma?” The rate for lifetime asthma prevalence was computed by dividing the number of
adults who reported lifetime asthma by the number of adults who responded and completed the
survey. The responses to the questions are weighted so that a population based estimated rate
could be calculated.

See Appendix E for list of asthma questions asked in the 2002-2004 Virginia BRFSS survey.


                                                                                              7
 Asthma in Virginia, 2006

Adult Asthma Prevalence
Table 2 describes the prevalence of current and lifetime asthma in Virginia and the U.S., by
survey year. Statewide, in 2004, 13.2 percent of adults reported that they had asthma at some
point in their lifetime and this estimate is similar to the U.S. rate. There was no significant
difference in lifetime and current asthma prevalence in Virginia from 2002 through 2004.
Prevalence of lifetime asthma in the U.S. has significantly increased in 2004 compared to 2002
and 2003.

       Table 2. Current and Lifetime Asthma Among Adults, Virginia and U.S. 2002-2004
                                   2002              2003                   2004
                           Percent 95%CI¤ Percent 95%CI¤ Percent 95%CI¤
      Virginia
       Current Asthma            7.2      (6.2-8.2)       7.6       (6.6-8.6)       7.3      (6.5-8.2)
       Lifetime Asthma          12.1     (10.1-13.3)     12.1     (10.9-13.3)      13.3    (12.1-14.5)
      United States
       Current Asthma            7.6      (7.3-7.7)       7.7       (7.5-7.9)       8.1      (7.9-8.3)
       Lifetime Asthma          11.8     (11.6-12.0)     11.9     (11.6-12.1)      13.3    (13.1-13.6)
    Source: Virginia Behavioral Risk Factor Surveillance System, 2002-2004. Percentages are weighted.
    U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System,
    http://www.cdc.gov/asthma/brfss/
    ¤CI–Confidence Interval (is a range of values within which there is a 95% chance that the true
    prevalence estimate lies).

According to Virginia BRFSS, in 2004, about 7.3 percent of adults had current asthma compared
to 7.6 percent in 2003 and 7.2 percent in 2002. In addition, the rate of current asthma
prevalence among Virginia adults was lower than the national estimate in 2004. In Virginia, an
overall trend in the current asthma prevalence remained steady from 2002 through 2004 (Table
2). See appendix B for detailed data tables on current and lifetime asthma prevalence in 2004.




                                                                                                         8
 Asthma in Virginia, 2006

Figure 1 indicates that Virginia adults, aged 35-44 years and 65 years and older, were more
likely to report current asthma than any other age group, and the rates were higher than the
national rate for the same age groups.

            Figure 1. Current Asthma Among Adults, by Age, Virginia and U.S., 2004
                    14.0

                    12.0

                    10.0                                                           9.1
                                     9.0                               8.4   7.9
                                           7.0 7.7     8.2 7.7                            8.1 7.4
                                                                 7.3
              Percent




                         8.0
                               5.1
                         6.0
                                                                                          Virginia
                         4.0
                                                                                          United States
                         2.0

                         0.0
                               18-24        25-34      35-44     45-54        55-64         65+

             Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
             U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance system
             http://www.cdc.gov/asthma/brfss/

Five percent of adults, aged 18-24 years, had the lowest current asthma prevalence rate in
Virginia compared to the U.S. rate of 9.0 percent in the same age group. The rate was
significantly lower for the 18-24 years age group in Virginia than that for the U.S. (Figure 1).

            Figure 2. Current Asthma Among Adults, by Sex, Virginia and U.S., 2004
                   14.0

                   12.0
                                                                             10.0 10.0
                   10.0
               Percent




                         8.0
                                                 6.1
                         6.0                                                             Virginia
                                           4.5
                         4.0                                                             United States

                         2.0

                         0.0
                                            Males                            Females

             Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
             U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance system,
             http://www.cdc.gov/asthma/brfss/

In 2004, 10.0 percent of females reported that they currently had asthma compared to 4.5
percent of males in Virginia. The current asthma prevalence rate was significantly higher for
females than males in Virginia and in the U.S. (Figure 2). In addition, Virginia males had a lower
rate of current asthma prevalence than the U.S. males.


                                                                                                             9
    Asthma in Virginia, 2006

Figure 3 shows that current asthma prevalence rates among all racial/ethnic groups were lower
in Virginia than for that of the U.S in 2004. Approximately 12.0 percent of multiracial groups and
7.9 percent of blacks, had a higher current asthma prevalence rate than whites, others, and
Hispanics in Virginia.

       Figure 3. Current Asthma Among Adults, by Race and Ethnicity, Virginia and U.S., 2004
                            20.0
                            18.0
                            16.0                                                             Virginia
                                                                                    14.0
                            14.0
                                                                             11.9            United States
                            12.0
                  Percent




                                                           9.1
                            10.0
                                       7.3 8.2       7.9               8.0
                             8.0
                                                                                              5.1   6.2
                                6.0                              4.8
                                4.0
                                2.0
                                0.0
                                       White          Black       Other      Multiracial     Hispanic


                 Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
                 U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System.
                 http://www.cdc.gov/asthma/brfss/

Current asthma prevalence rate was higher among multiracial adults than any other race and
ethnicity groups in Virginia and in the U.S. (Figure 3).

              Figure 4. Current Asthma Among Adults, by Income, Virginia and U.S., 2004
                                20.0
                                18.0
                                16.0                                                        Virginia
                                       14.5
                                14.0
                                              11.1                                          United States
                                12.0
                                10.0                  9.6 9.2
                      Percent




                                 8.0                             7.1 7.7            7.5           6.9
                                 6.0                                          5.7           6.0
                                 4.0
                                 2.0
                                 0.0
                                       Less than     $15,000-    $25,000-    $50,000-      $75,000 or
                                        $15,000      $24,999     $49,999     $74,999         more

                   Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
                   U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor
                   Surveillance System. http://www.cdc.gov/asthma/brfss/

There appears to be a statistically significant relationship (p<0.05) between current asthma
prevalence rate and annual household income4. Current asthma prevalence was significantly
higher among adults with annual incomes of less than $15,000, as compared to adults with
annual incomes of $75,000 or more, in Virginia and in the U.S. (Figure 4).
4
    The income refers to self-reported total annual household income.


                                                                                                                  10
 Asthma in Virginia, 2006

Current asthma prevalence varied by self-reported educational attainment. There was a
significant relationship (p<0.05) between the rate of current asthma prevalence and education.
According to Virginia BRFSS, in 2004, 11.9 percent of adults, with less than a high school level
of education, had a significantly higher rate of current asthma than that of other groups (Figure
5). Virginia compared favorably to the U.S., specifically among those with some college or a
college degree.

         Figure 5. Current Asthma Among Adults, by Education, Virginia and U.S., 2004
                         18.0
                         16.0
                                                                                      Virginia
                         14.0
                                                                                      United States
                                  11.9
                         12.0
               Percent




                                         9.7                               8.7
                         10.0
                                                     7.3   7.7                              7.4
                          8.0
                                                                     6.6              6.5
                          6.0
                          4.0
                          2.0
                          0.0
                                Less than High   High School/GED   Some college   College graduate
                                   School

              Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
              U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor
              Surveillance System. http://www.cdc.gov/asthma/brfss/

Nationally, adults with less than a high school level of education were significantly more likely to
report having current asthma than adults with a college degree (Figure 5).




                                                                                                             11
 Asthma in Virginia, 2006

Figure 6 shows, current smoking behavior by current asthma status in 2004. Twenty- four and
half percent of Virginia adults with current asthma were current smokers, compared to 20.5
percent of adults without asthma. There were no significant differences in smoking status
between adults with current asthma and adults without current asthma. However, these results
indicate that people with current asthma continue to smoke. Smoking and environmental
tobacco smoke (also known as secondhand smoke) can trigger asthma symptoms in adults and
children.

      Figure 6. Smoking Status Among Adults, by Current Asthma Status, Virginia, 2004
                  120.0
                  110.0
                  100.0
                   90.0
                   80.0                 75.5                             79.5
                   70.0
             Percent




                   60.0                                                         Current smoker
                   50.0
                                                                                Non-smoker
                   40.0
                   30.0          24.5
                   20.0                                           20.5
                   10.0
                    0.0
                              Current Asthma                      No Asthma

            Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.

The survey respondents who had smoked cigarettes at least 100 days in their lifetime, and
respondents who smoked some days or everyday, were defined as current smokers. Those who
were former smokers or who had never smoked were defined as non-smokers.




                                                                                                           12
 Asthma in Virginia, 2006

During the BRFSS survey in 2004, Virginia adults were asked to grade their general health
status as excellent/ very good, good, or fair/poor. There were overall statistically significant
relationships between Virginians with and without current asthma and self-reported general
health status (p<0.05). Virginians with current asthma were significantly less likely to grade their
general health status as excellent/very good as compared to those without current asthma
(Figure 7).

    Figure 7. General Health Status Among Adults, by Current Asthma Status, Virginia, 2004
                       90.0
                       80.0
                       70.0
                                                                   60.7      Excellent/Very Good
                       60.0                                                  Good
                       50.0                                                  Fair/Poor
             Percent




                                38.3
                       40.0
                                       33.6                               27.9
                       30.0                   28.2

                       20.0
                                                                                 11.4
                       10.0
                        0.0
                               Current Asthma                       No Asthma

             Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.

In Virginia, only 38.3 percent of adults with current asthma considered themselves in
excellent/very good health compared to 60.7 percent of adults who did not have asthma.
Virginians with current asthma were significantly more likely to grade their general health status
as fair/poor as compared to those without current asthma (Figure 7). Approximately 28.2 percent
of Virginians with current asthma considered themselves in fair/poor health compared to 11.4
percent of adults without current asthma.




                                                                                                            13
 Asthma in Virginia, 2006

Obesity has been pointed out as a risk factor for higher prevalence of asthma and asthma-
related symptoms in adults [9]. Therefore, weight management for overweight and obese people
with asthma may be an important component in the medical care of these people [10]. Obesity
was defined as a body mass index (BMI) greater than or equal to 30. BMI is a number that
shows body weight adjusted for height and it is calculated by dividing weight by height [11].

       Figure 8. Weight Status Among Adults, by Current Asthma Status, Virginia, 2004
                        70.0

                        60.0                                          Not overweight/obese
                                                                      Overweight
                                                                      Obese
                        50.0
                                                                 40.5 37.3
              Percent




                        40.0
                               33.3 32.4 34.4
                        30.0
                                                                             22.2
                        20.0

                        10.0

                         0.0
                               Current Asthma                     No Asthma

             Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.

In Virginia, there was a significant relationship between weight status and the risk for current
asthma (p<0.05). Figure 8 indicates that the percent of respondents who reported being obese
were significantly higher among adults with current asthma than adults without current asthma
(34.4% versus 22.2%). For adults who had current asthma, 32.4 percent were overweight
compared to 37.3 percent of adults without current asthma. Virginians with current asthma were
less likely to report their weight status as not overweight/obese as compared to those without
current asthma (Figure 8).




                                                                                                            14
 Asthma in Virginia, 2006

Among the triggers of asthma, upper respiratory tract infections are one of the common and
more serious in patients with asthma, and they may lead to pneumonia or other acute
respiratory diseases. Influenza is a major cause of these upper respiratory tract infections.
According to CDC, all individuals with asthma should receive a flu vaccination as a part of
routine care [12].

Figure 9. Influenza Vaccination Status Among Adults, by Current Asthma Status, Virginia, 2004
                   100.0
                        90.0
                        80.0
                        70.0                                            65.9
                                        52.5
                        60.0
              Percent




                        50.0     47.5
                                                                               Vaccinated
                                                                 34.1
                        40.0                                                   Not-Vaccinated
                        30.0
                        20.0
                        10.0
                         0.0
                               Current Asthma                    No Asthma
             Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.

There was a significant difference (P<0.05) in receiving influenza vaccinations among Virginians
with and without current asthma. Adults with current asthma more significantly reported
receiving an influenza vaccination in the past year than those without current asthma (Figure 9).
In 2004, 47.5 percent of Virginians with current asthma reported that they received influenza
vaccinations compared to 34.1 percent of adults without current asthma. However, among adults
with current asthma, more than half (52.5%) did not receive influenza vaccinations in the past 12
months in Virginia (Figure 9). Therefore, there is obviously a need to increase the proportion of
people with asthma, who receive an annual influenza vaccination.




                                                                                                            15
 Asthma in Virginia, 2006

According to the 2004 BRFSS, only 22 percent of Virginia’s populations lived in a small town, yet
those living in small towns had the highest rate (8.2%) of current asthma (Figure 10).

Figure 10. Geographic Density Status Among Adults, by Current Asthma Status, Virginia, 2004
                        12.0

                        10.0
                                                                                     8.2
                                                              7.7
                         8.0
                                                        6.7
              percent




                                 6.0
                         6.0

                         4.0

                         2.0

                         0.0
                                Urban              Suburban   Rural             Small town

             Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.

  Figure 11. Health Insurance Status Among Adults, by Current Asthma Status, Virginia, 2004

                        120.0
                        110.0
                        100.0
                                          87.5                         85.7
                         90.0
                         80.0
                         70.0                                                        Insured
              Percent




                         60.0                                                        Uninsured
                         50.0
                         40.0
                         30.0
                                                 12.5                         14.3
                         20.0
                         10.0
                          0.0
                                       Current Asthma                 No Asthma

             Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.

Figures 11 shows, 12.5 percent of Virginians with current asthma reported that they had no
health insurance coverage in the past year compared to 14.3 percent of those without current
asthma. There was no significant difference in health insurance status between adults with
current asthma and adults without current asthma.




                                                                                                            16
    Asthma in Virginia, 2006

The 2004 current asthma prevalence rates by Virginia Health Districts are mapped in figure 12.
Among the 35 Health Districts (HD), 22 districts had current asthma prevalence rates above the
state rate of 7.3 percent (Table 12). Health Districts that had the highest rates were Lenowisco
(11.7%), Chesapeake (11.7%), Arlington (10.9%), Richmond City (10.8%), Hanover5 (10.4%),
and Norfolk (10.4%).

             Figure 12. Current Asthma Among Adults, by Health District, Virginia, 2004




Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.

A detailed data table for current asthma prevalence in Virginia’s HD can be found in Appendix B.




5
 Hanover Health District, located in the central region of the state, has been renamed Chickahominy Health District,
as of July 2006



                                                                                                                 17
    Asthma in Virginia, 2006

Asthma Management and Control
Appropriate management improves the quality of life for people with asthma. There are various
ways to illustrate the impact of asthma management, control, and quality of life, such as
frequency of asthma attacks, activity limitations, and frequency of emergency department visits.
The 2003-2004 Virginia BRFSS Adult Asthma History Module included nine questions that
measured these concepts. The Adult Asthma History questions were asked to adult respondents
who reported that they have current asthma. Due to the limited number of survey respondents in
each year, findings from the 2003 through 2004 were combined (unless otherwise noted) to
obtain statistically reliable rates. See Appendix E for questions asked on Adult Asthma History in
the 2003 and 2004 Virginia BRFSS. Detailed data tables on Adult Asthma History can found in
appendix B.

    Figure 13. Asthma Attack Among Adults with Current Asthma in the Past 12 Months, Virginia,
                                          2003-20046




                        No
                       49.4%

                                                                              Yes
                                                                             50.6%




               Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
               Percentages are weighted.

The likelihood and frequency of asthma attacks are related to the severity of each person’s
disease and the degree to which good medical and self-management practices have been
implemented. Appropriate management should lead to fewer asthma attacks. Virginia BRFSS
data from 2003 through 2004 revealed approximately 51 percent of adults with current asthma
reported an asthma attack in the past year (Figure13).

These attacks were significantly more frequent in females than males (56.3% versus to 38.9%).
Asthma attacks were also higher in whites than blacks and multiracial (51.8% versus 43.9% and
44.8% respectively), the uninsured than the insured (59.3% versus 49.0%), and current smokers
than non-smokers (57.6% versus 48.2%).



6
 Due to small number of survey respondents in each year, findings from the 2003 and 2004 Adult Asthma History
were aggregated (unless otherwise noted) to obtain statistically reliable rates.




                                                                                                            18
 Asthma in Virginia, 2006

Asthma attacks varied somewhat by age group (Figure14). The highest rates of asthma attacks
were seen among adults aged 35-44 years (57.4%), followed by 18-24 (55.1%) years, and with
lower rates in the 65 years and older age group (38.6%). The rates were higher in younger age
groups than the older age groups.

 Figure 14. Asthma Attack Among Adults with Current Asthma in the Past 12 Months, by Age,
                                  Virginia, 2003-2004
                       90.0
                       80.0
                       70.0
                               55.1        53.2          57.4
                       60.0
                                                                          49.9       48.2
             Percent




                       50.0
                                                                                               38.6
                       40.0
                       30.0
                       20.0
                       10.0
                        0.0
                              18-24       25-34          35-44         45-54        55-64      65+

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Figure 15. Asthma Attack Among Adults with Current Asthma in the Past 12 Months, by Income,
                                   Virginia, 2003-2004
                       90.0
                       80.0
                       70.0
                                 59.4             53.8             55.8            52.0
                       60.0
                                                                                               42.9
             Percent




                       50.0
                       40.0
                       30.0
                       20.0
                       10.0
                        0.0
                              Less than     $15,000 -            $25,000 -       $50,000 -   $75,000 or
                               $15,000       $24,999              $49,999         $74,999      more

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Figure15 shows that from 2003 through 2004 asthma attacks were less frequent (42.9%) in
Virginia in higher income groups with annual incomes of $75,000 or more, compared to the
income groups with annual incomes of less than $15,000 (59.4%).




                                                                                                          19
 Asthma in Virginia, 2006

People with asthma may experience some limitations in their daily activities, which may result in
absence from work or school. One of the important goals of asthma management is to reduce
limitation in regular activities, missed days of work, and school.

    Figure 16. Activity Limitations Among Adults with Current Asthma in the Past 12 Months,
                                       Virginia, 2003-2004
                                 One or two           3-5 days 6-9 days
                                   days                 4.7%     2.2%     10 or more days
                                   18.2%
                                                                                9.6%




                           No days
                            65.3%

              Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
              Percentages are weighted.

From 2003 through 2004, about 35 percent of Virginians with current asthma said that they were
unable to work or carry out their usual activities due to their asthma, while 65 percent had not
been restricted in their activities in the past year (Figure16). Among adults with current asthma
and restricted activities, 18 percent experienced limited activity at least one or two days. Activity
limitation due to asthma was less frequent (25.2%) among adults aged 65 years and older,
although it did not vary in a consistent way by age group. These limitations were more likely in:
females than males (36.5% versus 30.9%), blacks than whites (37.4% versus 34.3%), the
uninsured than the insured (37.8% versus 34.1%), and smokers than non-smokers (39.7%
versus 32.8%).




                                                                                                  20
 Asthma in Virginia, 2006

Figure 17 reveals that activity limitations were higher among adults with education levels of less
than high school (45.8%) compared to adults with education levels of college graduate or higher
(31.0%).

  Figure 17. Activity Limitations Among Adults with Current Asthma in the Past 12 Months, by
                                  Education, Virginia, 2003-2004
                          70.0
                          60.0
                                              45.8
                          50.0
                                                                                 38.0
                          40.0
               Percent




                                                              29.8                                31.0
                          30.0
                          20.0

                          10.0
                               0.0
                                      Less than High High School/GED Some college              College or
                                         School                                                 higher

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

  Figure 18. Activity Limitations Among Adults with Current Asthma in the Past 12 Months, by
                                   Income, Virginia, 2003-2004
                       70.0

                       60.0

                       50.0            46.4

                                                       38.9            38.3
             Percent




                       40.0
                                                                                        25.6        27.9
                       30.0

                       20.0

                       10.0

                         0.0
                                     Less than       $15,000 -       $25,000 -     $50,000 -     $75,000 or
                                      $15,000         $24,999         $49,999       $74,999        more
             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Activity limitation among adults with current asthma varied with annual household income in
Virginia from 2003 through 2004. Virginians with an annual income less than $15,000 reported
more frequent limitations in activity compared to Virginians with an annual income of $75,000 or
more, in the past year (Figure18).




                                                                                                              21
 Asthma in Virginia, 2006

Asthma symptoms have a tendency to get worse at night, possibly due to nighttime increases in
airway inflammation and bronchial sensitivity. Nighttime airway narrowing in asthma is often
associated with sleep disorders, such as episodes of nocturnal and early morning awakening,
difficulty in staying asleep, and daytime drowsiness. [13] One study concluded that impaired
quality of sleep, with disturbed sleep during the night, early morning awakenings, and daytime
sleepiness, is common among patients with bronchial asthma. [14]

 Figure 19. Sleeping Difficulty Among Adults with Current Asthma in the Past 30 Days, Virginia,
                                          2003-2004
                                1-2 days                      3-4 days
                                                               11.6%     5 days
                                 18.6%
                                                                          3.6%
                                                                            6-10 days
                                                                               5.4%


                                                                           More than 10
                                                                              days
                                                                              8.5%


                                  No days
                                   52.3%

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Figure 19 shows, among adults with current asthma, about half (48%) reported that they had
difficulty in sleeping in the past 30 days because of their asthma symptoms. Most of those
reported having difficulty in sleeping for one or two days. There was a significant relationship
between age, annual household income, and sleeping difficulty (p value <0.05). Sleeping
difficulty was more frequent in: blacks than whites (52.4% versus 43.5%), the uninsured than the
insured (56.5% versus 45.9%), Virginians with less education than Virginians with more
education (51.3% versus 44.5%), and smokers than non-smokers (56.7% versus 44.5%).




                                                                                             22
 Asthma in Virginia, 2006

The percent of adults with current asthma that reported sleeping difficulty varied somewhat by
age groups. The highest rates were seen in adults aged 35-44 years, with lower rates in younger
and older age groups (Figure 20). Sleeping difficulty among adults aged 35-44 years was
significantly higher than adults aged 65 years and older. Note: The 18-24 years had fewer than
50 respondents; use caution when interpreting rates for this age group.

 Figure 20. Sleeping Difficulty Among Adults with Current Asthma in the Past 30 Days, by Age,
                                      Virginia, 2003-2004
                        90.0
                        80.0
                        70.0
                        60.0                              59.3
                                                                                     52.7
              Percent




                        50.0               50.0                           50.3

                        40.0   35.2
                                                                                               31.5
                        30.0
                        20.0
                        10.0
                         0.0
                               18-24*      25-34          35-44        45-54        55-64      65+

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted. *Number of survey respondents less than 50.
             Rates should be interpreted with caution.

    Figure 21. Sleeping Difficulty Among Adults with Current Asthma in the Past 30 Days, by
                                   Income, Virginia, 2003-2004
                        90.0
                        80.0
                        70.0
                        60.0     56.5              59.1
              Percent




                        50.0                                       48.0            42.6
                        40.0
                                                                                                31.5
                        30.0
                        20.0
                        10.0
                         0.0
                               Less than     $15,000 -           $25,000 -       $50,000 -   $75,000 or
                                $15,000       $24,999             $49,999         $74,999      more

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

The rate of experiencing sleeping difficulty due to asthma varied across income levels. Figure 21
reveals that reported sleeping difficulty was less in the higher income groups as compared to
low-income groups in the past 30 days in Virginia. Sleeping difficulty was significantly more
frequent (59.1%) among Virginia adults with an annual incomes of $15,000-$24,999, compared
to Virginia adults with an annual incomes $75,000 or more (31.5%).


                                                                                                          23
 Asthma in Virginia, 2006

Environmental exposures are one of the risk factors that trigger asthma. Genetic factors also
influence some people to develop asthma, especially if they are exposed to contributing agents,
and certain other factors that can trigger symptomatic episodes of asthma in those who have
already developed the disease. Certain clinical characteristics differentiate asthma from other
chronic lung conditions. The most important of these is that the symptoms and functional
disability caused by asthma vary from one circumstance to another. [15] Symptoms once per
day or more frequently than once per day are markers of inadequately managed asthma. The
goal of treatment is to achieve proper management of the symptoms before an asthma attack.

Figure 22. Asthma Symptoms Among Adults with Current Asthma in the Past 30 Days, Virginia,
                                    2003-2004
                                  <1 time a week
                                                                      1-2 times a
                                       (18.4%)
                                                                         week
                                                                        (22.2%)




                Not at any time
                    (31.4%)                                                >2 times a week
                                                                               (not daily)
                                                                                (10.3%)
                                   Everyday, all the       Every day, not all
                                         time              the time (13.7%)
                                        (3.9%)
            Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
            Percentages are weighted.

Approximately 69 percent of Virginia adults with current asthma reported asthma symptoms in
the past 30 days compared to 31 percent who reported no such symptoms. The majority of them
had asthma symptoms once or twice a week (Figure 22). There was a significant relationship
between annual household income, health insurance status, and asthma symptoms (p value
<0.05). Asthma symptoms were more frequent in smokers than non-smokers (73.0% versus
67.4%). Females and males reported asthma symptoms in the past 30 days with about the
same frequency (67.5% and 70.7%, respectively). Seventy one percent of blacks reported
having asthma symptoms compared to 68.4 percent of whites. The rate of asthma symptoms in
other races and ethnicities were not presented because of the small sample size. The reported
rate of asthma symptoms among adults with current asthma in the past the 30 days did not have
a consistent pattern by age group. Asthma symptoms varied by health insurance coverage. The
rate of asthma symptoms among Virginians without health insurance was significantly higher
than those with health insurance (81.8% versus 66.4%).




                                                                                             24
 Asthma in Virginia, 2006

Adults with current asthma who had less years of education were more likely to report asthma
symptoms in the past 30 days, compared to adults with more years of education (Figure 23).

   Figure 23. Asthma Symptoms Among Adults with Current Asthma in the Past 30 Days, by
                             Education, Virginia, 2003-2004
                                 100.0
                                  90.0
                                  80.0          74.1               75.5
                                  70.0                                                 65.8            62.1
                                  60.0
                       Percent




                                  50.0
                                  40.0
                                  30.0
                                  20.0
                                  10.0
                                   0.0
                                         Less than High         High               Some college      College or
                                            School           School/GED                               higher

               Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
               Percentages are weighted.

   Figure 24. Asthma Symptoms Among Adults with Current Asthma in the Past 30 Days, by
                              Income, Virginia, 2003-2004
                       120.0
                       110.0
                       100.0
                        90.0             83.9
                        80.0                              76.4
                                                                            68.4              63.4
             Percent




                        70.0
                        60.0                                                                               59.9
                        50.0
                        40.0
                        30.0
                        20.0
                        10.0
                         0.0
                                     Less than         $15,000 -          $25,000 -      $50,000 -      $75,000 or
                                      $15,000           $24,999            $49,999        $74,999         more

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Figure 24 shows that the rate of asthma symptoms in the past 30 days varied with annual
income. Virginia adults with incomes less than $15,000 were significantly more likely to report
asthma symptoms than Virginia adults with incomes of $75,000 or more.




                                                                                                                     25
 Asthma in Virginia, 2006

Health care visits for urgent treatment of worsening asthma symptoms indicate poor medical or
patient self-management of the disease. More than a quarter (29%) of Virginia adults with
current asthma reported they required professional health care in the past 12 months for their
worsening asthma symptoms. The majority sought health care once or twice in the past year
(figure 25). Health care visits for urgent treatment of worsening asthma symptoms were more
frequent in blacks than whites (32.1% versus 27.4%) in the past 12 months. The rate of seeking
health care for urgent treatment of worsening asthma symptoms was significantly higher in
females than in males (33.4% versus 20.1%).

    Figure 25. Health Care Visits Among Adults with Current Asthma in the Past 12 Months,
                                     Virginia, 2003-2004
                                                          3-5 visits 6-9 visits
                                 1-2 visits                 8.5%       1.2% 10 or more
                                   17.3%                                        2.0%




                                No visits
                                 71.0%
             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Figure 26. Health Care Visits Among Adults with Current Asthma in the Past 12 Months, by Age,
                                     Virginia, 2003-2004
                       60.0

                       50.0
                                                   38.8
                       40.0
                                                                33.6
             Percent




                                                                          26.3
                       30.0
                              24.3          23.3                                    20.9
                       20.0

                       10.0

                        0.0
                              18-24      25-34     35-44       45-54     55-64      65+
             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Health care visits varied across age groups (Figure 26). Virginia adults between 35-54 years of
age were more likely to seek professional health care for their worsening asthma symptoms in
the past 12 months than adults in all other age groups.


                                                                                            26
 Asthma in Virginia, 2006

Figure 27 shows Virginians with lower annual incomes had more professional health care visits
for their asthma symptoms than higher income groups.

  Figure 27. Health Care Visits Among Adults with Current Asthma in the Past 12 Months, by
                                 Income, Virginia, 2003-2004
                       60.0

                       50.0

                       40.0                                35.7
             Percent




                                          29.5                               31.0          29.6
                       30.0
                                                                                                           20.8
                       20.0

                       10.0

                         0.0
                                        Less than       $15,000 -          $25,000 -     $50,000 -      $75,000 or
                                         $15,000         $24,999            $49,999       $74,999         more

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

  Figure 28. Health Care Visits Among Adults with Current Asthma in the Past 12 Months, by
                                Education, Virginia, 2003-2004
                                 50.0

                                 40.0
                                                 33.3
                                                                    28.9                28.9               27.1
                       Percent




                                 30.0

                                 20.0

                                 10.0

                                  0.0
                                          Less than High    High School/GED         Some college     College or higher
                                             School

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Virginians with less education were more likely to seek professional health care in the past
twelve months because of their worsening asthma than Virginians with more education (Figure
28). There was no consistent pattern observed in seeking professional health care in the past 12
months by availability of health insurance or by smoking status.




                                                                                                                         27
 Asthma in Virginia, 2006

The majority of patients with acute asthma attacks generally seek treatment in hospital
emergency department (ED) or other urgent care centers [15]. Most ED visits for asthma are
preventable with proper treatment and management. Studies show that effective asthma
education during regular physician office visits may decrease the frequency of ED utilization for
asthma attacks. [17]

   Figure 29. Emergency Department/ Urgent Care Center Visits Among Adults with Current
                    Asthma in the Past 12 Months, Virginia, 2003-2004




               No visits                                                1-2 visits
                79.1%                                                     17.0%




                                                                       3-5 visits
                                                                         3.0%
                                                                     6 or more visits
                                                                           0.9%

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

In Virginia, approximately 21 percent of adults with current asthma visited an ED or other urgent
care centers in the past 12 months because of their asthma. People who visited an ED or an
urgent care center were most likely to visit one or two times in the past 12 months (Figure 29).

The rates of ED/urgent care center visits were significantly higher in females than in males
(25.4% and 11.5%, respectively) and in adults with less than a high school degree than those
with a college degree or higher (33.3% versus 14.5%). These visits were more frequent in:
blacks than whites (29.1% versus 17.3%), smokers than non-smokers (26.0% versus 18.9%),
and the uninsured than the insured (23.5% versus 20.3%).




                                                                                              28
 Asthma in Virginia, 2006

The rates of ED or urgent care center visits for asthma in the past 12 months were higher in
younger adults than those aged 55 years and older (Figure 30).

   Figure 30. Emergency Department/ Urgent Care Center Visits Among Adults with Current
                 Asthma in the Past 12 Months, by Age, Virginia, 2003-2004
                       40.0


                       30.0
                              25.5        26.0
                                                       22.9
                                                                       21.5
             Percent




                       20.0
                                                                                       14.9        14.3

                       10.0


                        0.0
                              18-24       25-34        35-44          45-54         55-64          65+

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

   Figure 31. Emergency Department/ Urgent Care Center Visits Among Adults with Current
                Asthma in the Past 12 Months, by Income, Virginia, 2003-2004
                       50.0

                       40.0

                                26.6          29.5
                       30.0
             Percent




                                                               23.9
                       20.0
                                                                                12.5             15.1
                       10.0

                        0.0
                              Less than    $15,000 -      $25,000 -           $50,000 -       $75,000 or
                               $15,000      $24,999        $49,999             $74,999          more

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Figures 31 show rates of ED or urgent care center visits varied across the income levels. In the
past 12 months, the higher income groups were less likely to visit ED or urgent care centers for
their asthma.




                                                                                                           29
 Asthma in Virginia, 2006

Asthma patients experience varying symptoms and severity due to the nature of asthma,
exposure to environmental triggers, or insufficient adherence to medications. For these reasons,
people with asthma need routine follow up visits and adjustments in therapy for proper asthma
management. According to the NAEPP guidelines, the first routine check-up should be within a
month after an initial diagnosis. After that, the patient should be seen every one to six months
depending on the severity of asthma and patient’s capability to control the symptoms. [6]

    Figure 32. Routine Check-up Among Adults with Current Asthma in the Past 12 Months,
                                   Virginia, 2003-2004

                                     3-5 visits   10 or more
                                       12.9%         2.5%
                        6-9 visits
                          2.0%
                                                                                 No visits
                                                                                  44.0%




                        1-2 visits
                          38.5%



             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Among Virginians with current asthma, more than half (56%) visited a health care provider
(doctor, nurse, or other health professionals) in the past 12 months for a routine check-up. In the
past 12 months, Virginians who visited their health care provider for routine asthma check-up
generally reported one or two visits (Figure 32).

Routine check-ups for asthma was higher in women than men in the past 12 months. Whites
(56.0%) and blacks (57.5%) had similar patterns of visits to health care providers for routine
check-ups for asthma. Virginians without health insurance were significantly less likely to visit
their healthcare provider for an asthma check-up in the past 12 months compared to Virginians
with health insurance (38.4% versus 58.9%). In the past 12 months, there was no consistent
pattern between annual income and the rate of seeking routine check-ups for asthma.




                                                                                                30
 Asthma in Virginia, 2006

Getting a routine checkup for asthma varied by age. Virginia adults, aged 18-24 years, were
significantly less likely to visit their healthcare provider for an asthma check-up in the past 12
months as compared to Virginia adults aged 65 years and older (Figure 33).

Figure 33. Routine Check-up Among Adults with Current Asthma in the past 12 Months, by Age,
                                   Virginia, 2003-2004
                    100.0
                        90.0
                        80.0
                        70.0                                                                          67.7
                        60.0                                     54.2     60.5          59.6
                                                     51.4
              Percent




                        50.0
                        40.0         38.5
                        30.0
                        20.0
                        10.0
                             0.0
                                     18-24          25-34       35-44     45-54     55-64             65+
             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

  Figure 34. Routine Check-up Among Adults with Current Asthma in the Past 12 Months, by
                              Education, Virginia, 2003-2004
                             100.0
                              90.0
                              80.0
                              70.0           62.9
                              60.0                             52.9          56.3              55.1
                   Percent




                              50.0
                              40.0
                              30.0
                              20.0
                              10.0
                               0.0
                                     Less than High            High      Some college      College or
                                        School              School/GED                      higher
             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

According to the Virginia BRFSS from 2003 through 2004, the rate of seeking routine check-ups
varied by educational attainment. Those who have fewer years of education were more likely to
seek routine check-up for asthma in the past twelve months than those with more education
(Figure 34).




                                                                                                             31
 Asthma in Virginia, 2006

During past decades, major enhancements have been accomplished in the management of
acute asthma. Current evidence indicates that long-term control medications are necessary to
prevent exacerbations and symptoms for patients with asthma. [6]

 Figure 35. Asthma Medication Usage Among Adults with Current Asthma in the Past 30 Days,
                                   Virginia, 2003-2004

                                             Did not take any
                                                  30.2%




                                                                                       >1 time a week
                                                                                            8.9%




                                                                                           1-2 times a week
                                                                                                 13.1%
                  2 or more times a day
                         22.9%




                                                                       >2 times a week (not daily)
                                                                                  4.8%

                                                     1 time everyday
                                                          20.1%




             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

Among Virginians who currently had asthma in 2003-2004, usage of asthma medication in the
past 30 days varied (Figure 35). Approximately 70 percent of people with current asthma took
prescribed asthma medicine at least once in the past 30 days, compared to 30 percent of those
who did not take any. The majority of the people took medicine two or more times a day.
Females (70.1%) were as likely as males (69.0%) to take medication for their asthma. The rate
of taking asthma medication was similar for whites (69.1%) as compared to blacks (73.2%) and
multiracial (70.7%). About 74 percent of Virginians without health insurance stated that they took
prescribed medication for asthma in the past 30 days compared to 69 percent of Virginians with
health insurance. Virginia adults with annual incomes of less than $15,000 were significantly
more likely to have taken prescribed asthma medication compared to Virginia adults with annual
incomes of $50,000 or more in the past 30 days.




                                                                                                              32
 Asthma in Virginia, 2006

Figure 36 indicates that people aged 55 years and older reported taking prescribed medication
in the past 30 days more often than people of younger age groups for asthma.

 Figure 36. Asthma Medication Usage Among Adults with Current Asthma in the Past 30 Days,
                                by Age, Virginia, 2003-2004
                 120.0
                 110.0
                 100.0
                                                                                        84.8        84.4
                  90.0
                  80.0
                                     63.7                                67.2
             Percent




                  70.0
                                                    62.3       60.3
                  60.0
                  50.0
                  40.0
                  30.0
                  20.0
                  10.0
                   0.0
                                     18-24          25-34      35-44     45-54         55-64        65+

             Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
             Percentages are weighted.

 Figure 37. Asthma Medication Usage Among Adults with Current Asthma in the Past 30 Days,
                             by Education, Virginia, 2003-2004
                             110.0
                             100.0
                              90.0
                                             74.1              75.5
                              80.0
                                                                                65.8
                              70.0
                   Percent




                                                                                                  62.1
                              60.0
                              50.0
                              40.0
                              30.0
                              20.0
                              10.0
                               0.0
                                      Less than High           High      Some college          College or
                                         School             School/GED                          higher

            Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
            Percentages are weighted.

In the past 30 days, adults with fewer years of education were more likely to report taking
prescribed asthma medication compared to adults with more years of education (Figure 37).




                                                                                                            33
 Asthma in Virginia, 2006

According to BRFSS data from 2003 through 2004, Virginians with current asthma appear to be
first diagnosed with asthma either in early childhood or in the middle of adulthood (Figure 38).
Forty-two percent of adults reported they were diagnosed with asthma when they were 10 years
old or younger.

   Figure 38. Reported Age at First Diagnosis of Asthma Among Adults with Current Asthma,
                                      Virginia, 2003-2004
                            18-34 years                             35-64 years
                               19.0%                                   21.2%


              11-17 years
                 12.8%
                                                                            65 or more
                                                                              years
                                                                               5.2%



                                                10 or younger
                                                    41.8%

              Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004.
              Percentages are weighted.

Among adults with current asthma, 41 percent of males and 27.8 percent of females reported
that their condition was diagnosed at or before age 10. Reported age at diagnosis also varied by
race with a higher percentage of blacks and multiracial being diagnosed with asthma at or
before age 10 in comparison to whites.




                                                                                             34
 Asthma in Virginia, 2006

Childhood Asthma Prevalence
Epidemiological surveys have indicated that there has been a remarkable increase in the
prevalence of asthma in children and young adults in the United States, but the reasons for the
increase are not yet clear. Since it seems unlikely that genetic factors would contribute to the
growing trend, environmental factors might play a key part in the development of childhood
asthma. [18]

During the past four decades, there have been significant developments in understanding the
pathophysiology of asthma. The physician’s major tool in establishing the diagnosis of asthma is
an excellent and accurate medical history including type, frequency, and circumstances of
asthma attacks. The burden of childhood asthma on the child, the family, and society is
increasing. [19] There are differences between adult and child asthma in terms of medication
usage because many children are not be able to use inhalers like an adult. The majority of
children are not able to perform a lung function assessment until the age of 6 years or older. [20]

Nationally, from 1980 to 1996, asthma prevalence among children increased by an average of
4.3 percent per year, from 3.6 percent to 6.2 percent. Children with low annual family incomes,
of minority populations, and children living in inner cities, experience disproportionately higher
morbidity and mortality due to asthma. Asthma accounts for 14 million days of school missed
annually in the U.S. [21]

Nationwide, asthma is the third-ranking cause of hospitalization among those younger than 15
years of age, and the estimated cost of treating asthma in those younger than 18 years of age is
$3.2 billion per year. Currently, there is no prevention or cure for asthma, but children and
adolescents with asthma can still have high quality, dynamic lives if they manage and control
their asthma. [21]

Based on the 2004 National Health Interview Survey (NHIS), about nine million children under
18 years of age (12%) had ever been diagnosed with asthma in the United States. Boys were
more likely than girls to have ever been diagnosed with asthma (15% versus 9%) and children
from low-income families (14%) were more likely to have ever been diagnosed with asthma than
children from high–income families. About four million children (6%) had an asthma attack in the
past 12 months. [22]




                                                                                                35
 Asthma in Virginia, 2006

According to 2004 BRFSS, 12.7 (215,472) percent of Virginia’s children had lifetime asthma and
9.0 (152,277) percent of children had current asthma. In addition, according to the National
Survey of Children’s Health (NSCH), 7.4 percent of Virginia children, aged 0-17 years, were
affected by asthma during the past 12 months, compared with 8.1 percent nationally in 2003
(Figure 39). [36]

Figure 39.Children/Youth, (Ages 0-17), Affected by Asthma During the Past 12 Months, Virginia
                                       and U.S., 2003
                   12.0

                   10.0
                                            7.4   8.1                                              Virginia
                        8.0
                                                                                                   United States
             Percent




                        6.0
                                                                                   4.7
                                                                                          4.0
                        4.0

                        2.0

                        0.0
                                Asthma reported, experienced              Asthma reported, did not
                                       health effects                    experienced health effects

            Source: National Survey of Children’s Health, 2003. Percentages are weighted.


 Figure 40. Impact of Children’s (Ages 0-17) Asthma on Family, Among Children with Asthma,
                                    Virginia and U.S., 2003
                        120.0

                        100.0
                                                                                   86.4
                                                                                          83.7
                         80.0
              Percent




                         60.0                                                                     Virginia
                                                                                                  United States
                         40.0
                                             13.6 16.3
                         20.0

                          0.0
                                Affects fam ily a great deal/m oderate    Affects fam ily little/not at all
                                                am ount

            Source: National Survey of Children’s Health, 2003. Percentages are weighted.

Figure 40 shows that the survey also found 13.6 percent of Virginia children with asthma whose
families were affected a great deal or a medium amount by their child’s asthma status compared
to 16.3 percent nationally. [36]




                                                                                                                   36
 Asthma in Virginia, 2006

Asthma Inpatient Hospitalizations
Asthma hospitalizations are generally considered preventable, and therefore, serve as an
indicator of less than optimal medical management and patient self-management skills.
Increases in asthma hospitalization rates may also indicate higher prevalence, increased
severity, or poorer control of the disease in the population. In 2004, there were 497,000 asthma
hospitalizations in the United States and hospitalization rates (age-adjusted and per 10,000
population) were highest among children aged 0-15 years. [23]

Asthma hospitalization rates are one useful indicator of the severity of the disease. Hospital
discharge data can be used to identify specific population groups at risk of morbidity and
mortality due to asthma. Hospitalization data are also important for defining where and what
kinds of programs are needed, as well as providing information for educational purposes and
targeting the specific groups for solid intervention to reduce hospitalizations.

This report presents data on inpatient hospitalization due to asthma in Virginia from 1999-2004,
including the number and rates of hospitalization for asthma, how the yearly trends in asthma
hospitalization changed for the period of 1999-2004, and how asthma hospitalization rates vary
by age, sex, race, and locality. Length of hospital stay and charges related to asthma
hospitalizations are also reported to further demonstrate the impact of asthma in the state.

There is no confirmed case classification for hospitalization for asthma. The Council of State and
Territorial Epidemiologists (CSTE) recommend a definition of a probable case of asthma when
the hospital discharge records indicate a primary diagnosis of asthma using ICD-9-CM Codes:
493.0- 493.9. [24]

Hospital discharge data were obtained from Virginia Health Information, Inc. (VHI). VHI data are
summarized by discharge, not by patient. Therefore, multiple discharges may occur for the same
patient. This analysis did not adjust for multiple discharges. Asthma hospitalization was defined
for this report as an inpatient asthma hospital discharge record of a Virginia resident listed with
the primary diagnosis of asthma. Virginia residents admitted to hospitals in other states are not
available. Virginia’s hospital discharge database includes discharges from all Virginia hospitals,
with the exception of military and Veterans Administration (VA) hospitals.

The hospital discharge rates due to asthma were calculated using the number of asthma
hospital discharges from 1999-2004 as the numerator and population estimates from the Virginia
annual population estimates from 1999-2004 as the denominator multiplied by 10,000. Rates
were age-adjusted to the 2000 U.S. standard population. See Appendix B for detailed data for
asthma hospitalizations from 1999-2004.




                                                                                                37
 Asthma in Virginia, 2006

In 2004, there were 9,460 hospital discharges with a primary diagnosis of asthma among
Virginia residents. The annual number of asthma hospitalizations in Virginia declined
approximately 11 percent, from 10,675 in 1999 to 9,460 in 2004. Virginia asthma hospitalization
rates were lower than U.S. rates from 1999 through 2004 (Table 3).

   Table 3. Annual Asthma Hospital Discharges and Rates (per 10,000), Virginia, 1999-2004
                                 1999      2000    2001      2002      2003      2004
      Number                    10,675 9,617       9,673     9,107    10,498 9,460

       Crude Rate                                15.5      13.5     13.4     12.5       14.2        12.6

       Age-Adjusted Rate*                        15.9      13.8     13.7     12.7       14.5        12.9

      Age-Adjusted Rate*(U.S.)                   17.4      16.7     16.0     16.8       19.8        17.0
     Source: Virginia Health Information Patient Level Data, 1999-2004.
     U.S. data: Centers for Disease Control and Prevention. National Center for Health Statistics. National
     Hospital Discharge Survey (NHDS). http://www.cdc.gov/nchs/about/major/hdasd/listpubs.htm
    *Rates are age-adjusted to the 2000 U.S. standard population. Hospital discharges where the primary
     diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

         Figure 41. Asthma Hospital Discharge Rates* (per 10,000) Virginia, 1999-2004
                                30.0

                                25.0
             Rate per 10,000)




                                20.0
                                       15.9
                                              13.8      13.7      12.7     14.5
                                15.0                                                   12.9

                                10.0

                                 5.0

                                 0.0
                                       1999   2000      2001      2002     2003        2004

            Source: Virginia Health Information Patient Level Data, 1999-2004.
            *Rates are age-adjusted to the 2000 U.S. standard population. Hospital discharges
             where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

The annual asthma hospitalization rate among Virginia residents went down about 19 percent
from 15.9 hospitalizations per 10,000 in 1999 to 12.9 hospitalizations per 10,000 in 2004 (Figure
41).




                                                                                                              38
 Asthma in Virginia, 2006

Figure 42 shows variations in hospital discharge rates for asthma by age. During the period from
1999 to 2004, the rate for asthma hospital discharge was highest for children under age 5 years,
followed by adults, age 65 years and older, compared to all other age groups.

    Figure 42. Asthma Hospital Discharge Rates* (per 10,000) by Age, Virginia, 1999-2004
                              60.0

                              50.0
                                                                                         0-4
            Rate per 10,000




                              40.0
                                                                                         5-14
                              30.0                                                       15-34
                                                                                         35-64
                              20.0                                                       65+

                              10.0

                               0.0
                                     1999   2000   2001   2002      2003        2004
           Source: Virginia Health Information Patient Level Data, 1999-2004.
           *Rates are age-specific. Hospital discharge where the primary diagnosis was asthma
           (ICD-9-CM codes 493.0-493.9).

In general, asthma hospitalization rates show descending trends over time for each age group,
except for people age 65 years and older. The high rates among adults aged 65 years and older
may be due to other respiratory diseases, such as Chronic Obstructive Pulmonary Disease
(COPD), which could be diagnosed incorrectly as asthma in the hospital discharge record.




                                                                                                 39
 Asthma in Virginia, 2006

Healthy People 2010, developed by the U.S. Department of Health and Human Services,
present a comprehensive health promotion and disease prevention program on a national scale
to accomplish the objectives for improving the health of all people of the United States during the
first decade of the new century. [25] The objectives that address asthma hospital discharges are
incorporated in the national Healthy People 2010.

Table 4. Asthma Hospital Discharge Rates (per 10,000) Virginia, 2004 and Healthy People 2010
                                    Objectives, by Age
                                                      U.S. Healthy People
                                     2004 VA Rate*
                                                           2010 Target
                 Age (Years)
                  0-4                      36.6                 25.0
                  5-64                      9.2                 7.7**
                  >65                      23.5                11.0**
                  Source: Virginia Health Information Patient Level Data, 2004.
                  U.S. data: U.S. Department of Health and Human Services, 2000.
                  http://www.healthypeople.gov *Rates are age-specific.
                  **Rates are age-adjusted to the 2000 U.S. standard population. Hospital discharges
                  where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

The Healthy People Objective 24-2 is to decrease the rate of hospitalizations for asthma to 25
per 10,000 in children under the age of 5 years, 7.7 per 10,000 among people aged 5 to 64
years, and 11 per 10,000 among adults 65 years and older [25]. To calculate these rates,
discharge with a primary diagnosis of asthma was considered for the numerator and resident
annual population estimates from Virginia and U.S. census were used for the denominator.

Table 4 shows that asthma hospitalization rates in Virginia across all age groups were higher
than the national baseline rates in 2004. To reduce these rates further and achieve 2010 target
rates, comprehensive, targeted asthma management and control strategies need to continue. A
list of objectives for Healthy People 2010 for asthma can be found in Appendix D.




                                                                                                       40
 Asthma in Virginia, 2006

In Virginia, the age-adjusted asthma hospital discharge rates were higher among females than
males from 1999 through 2004 (Figure 43). In 2004, the rate for females was 15.2 per 10,000
population compared to 10.2 per 10,000 population for males.

    Figure 43. Asthma Hospital Discharge Rates* (per 10,000) by Sex, Virginia, 1999-2004
                              30.0

                              25.0                                                       Male
                                                                                         Female
            Rate per 10,000




                              20.0

                              15.0

                              10.0

                               5.0

                               0.0
                                     1999   2000   2001      2002       2003       2004

              Source: Virginia Health Information Patient Level Data, 1999-2004.
            *Rates are age-adjusted to the 2000 U.S. standard population. Hospital discharges
                  where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

The overall asthma hospitalization rates have decreased from 1999-2004 in both genders with a
small peak in 2003. In 2004, 62 percent of discharges were for females compared to 38 percent
discharges for males.

Nationally, in 2004, the age-adjusted asthma hospital discharge rate for females was 19.4 per
10,000 population compared to 14.5 per 10,000 population for males. Virginia asthma
hospitalization rates were lower than U.S. rates for both males and females in 2004.




                                                                                                  41
 Asthma in Virginia, 2006

Figure 44 shows that asthma hospitalization rates varied by age and sex. Males, aged 0-14
years, had higher rates of hospitalization than females. Starting at age 15, females had a higher
rate of hospitalization for asthma. In addition, asthma hospitalization rates were highest among
children under the age of 5 years.

   Figure 44. Asthma Hospital Discharge Rates* (per 10,000) by Sex and Age, Virginia, 2004
                               60.0

                               50.0                                                         Males
                                      44.8
                                                                                            Females
             Rate per 10,000




                               40.0

                                             28.1                                               30.3
                               30.0
                                                    16.0
                               20.0
                                                                                  16.2   14.2
                                                           11.0
                               10.0
                                                                  2.8 5.8   5.7
                                0.0
                                        0-4          5-14         15-34     35-64          65+
             Source: Virginia Health Information Patient Level Data, 2004.
            *Rates are age-specific. Hospital discharges where the primary diagnosis was
             asthma (ICD-9-CM codes 493.0-493.9).

In children under the age of 15 years, some studies show asthma hospitalization rates to be
higher in males than females but the reason for the disparity that reflects gender difference in
asthma prevalence and severity is unclear [26].




                                                                                                       42
 Asthma in Virginia, 2006

Between 1999 and 2004, the hospital discharge rates were consistently highest for blacks
between all race and ethnic groups. The discharge rates for whites, others, and Hispanics
remained steady over time. There has been an overall decrease in asthma hospitalization rates
in Virginia in all race and ethnic groups (figure 45).

  Figure 45. Asthma Hospital Discharge Rates* (per 10,000) by Race/Ethnicity, Virginia, 1999-
                                           2004
                             40.0

                                                                                      White
                             30.0                                                     Black
           Rate per 10,000




                                                                                      Other

                             20.0                                                     Hispanic



                             10.0


                              0.0
                                    1999   2000   2001   2002    2003       2004

           Source: Virginia Health Information Patient Level Data, 1999-2004.
           *Rates are age-adjusted to the 2000 U.S. standard population. Hospital discharges
            where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

In 2004, the age adjusted rate of asthma hospitalization for blacks was 24.1 per 10,000
population compared to whites at 9.5 per 10,000 population. Minority populations continue to
experience a disproportionate share of hospitalizations due to asthma. Decreased asthma
hospitalizations in blacks and Hispanics with asthma have been established in various studies
over the past few years. These study results show that reduced asthma hospitalizations were
associated with optimal drug therapy according to national guidelines, patient education,
environmental factor control, and proper monitoring. [27]




                                                                                                 43
    Asthma in Virginia, 2006

Due to small numbers of asthma hospital discharges in other races and Hispanic populations,
findings from the 1999 through 2004 were combined to obtain statistically reliable rates. Black
Virginians experienced the highest rates of asthma hospitalization in all age groups (Figure 46).
The overall hospital discharge rate (age-adjusted) due to asthma for blacks was over two times
higher (38.1 per 10,000 population) than whites (14.3 per 10,000 Population) from 1999 to 2004.

Figure 46. Asthma Hospital Discharge Rates* (per 10,000) by Age and Race/Ethnicity, Virginia,
                                 1999- 2004 (Combined)7
                           120.0
                           110.0
                           100.0
                            90.0                                                   White
             Rate per 10,000




                            80.0                                                   Black
                            70.0                                                   Other
                            60.0                                                   Hispanic
                            50.0
                            40.0
                            30.0
                            20.0
                            10.0
                             0.0
                                   0-4   5-14         15-34         34-64          65+
            Source: Virginia Health Information Patient Level Data, 1999-2004 (combined).
            *Rates are age-specific. Hospital discharges where the primary diagnosis was
             asthma (ICD-9-CM codes 493.0-493.9).

Children, aged 0 to 4 years, and adults, aged 65 years and older experienced the highest
hospitalization rates in Virginia within each race and among Hispanics, compared to all other
age groups during this period (Figure 46).




7
  Due to small number of events in other race and Hispanic ethnicity, data from 1999 through 2004 were
aggregated to obtain the statistically reliable rates.




                                                                                                   44
 Asthma in Virginia, 2006

Figure 47 shows that asthma hospitalizations varied over the course of the year in Virginia.
When 2004 data were analyzed by date of admission, two peaks in hospitalizations in Virginia
were seen in January through March and in September through December. A smaller peak was
seen in May. The smallest number of hospitalizations was seen from June through August.

           Figure 47. Asthma Hospitalizations by Month of Admission, Virginia, 2004
                            1400

                            1200

                            1000
             Hospitalizations




                                800

                                600

                                400

                                200

                                  0
                                      Jan   Feb   Mar   Apr   May June July Aug   Sep   Oct   Nov   Dec
                Source: Virginia Health Information Patient Level Data, 2004. Asthma Hospitalizations where the
                primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

This seasonal trend was similar from 2002-2004. In 2004, there were 945 hospitalizations for
asthma in October compared to 484 hospitalizations in July. Seasonal variations in asthma are
commonly acknowledged. The seasonal variability in asthma hospitalizations suggests that
acute asthma is influenced by variables other than socioeconomic factors and adherence to
treatment regimen. Therefore, individual seasonal history is significant for asthma management.
[28]

The higher number of asthma hospitalizations in the winter and fall seasons might be due to the
presence of seasonal allergens, increased time spent indoors leading to exposure to possible
triggers like house dust mites, molds, animal dander and tobacco smoke, and upper respiratory
tract infections. In addition, the cause of asthma hospitalizations during the fall might also be
repeated due to the decay of fallen leaves. Molds are at an increased level during the fall, and
stay high until winter. [29]




                                                                                                              45
 Asthma in Virginia, 2006

The 2002-2004 hospital discharge rates due to asthma by Virginia Health Districts are mapped
in figures 48 through 50. Rates for each Health District are listed in Table 19 in Appendix B.
There were variations in asthma hospitalizations by Health District.

   Figure 48. Asthma Hospital Discharge Rates* (per 10,000) by Health District, Virginia, 2002




Source: Virginia Health Information Patient Level Data, 2002. Rates are age-adjusted to the 2000 U.S. standard
population. Hospital discharges where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

In 2002, Richmond City (34.1 per 10,000), Crater (26.5 per 10,000), Cumberland Plateau (23.0
per 10,000), Piedmont (22.9 per 10,000), and West Piedmont (21.7 per 10,000) Health Districts
had the highest hospitalization rates for asthma, higher than that for the state rate (12.7 per
10,000).




                                                                                                                 46
 Asthma in Virginia, 2006

Eighteen of thirty-five Health Districts had higher age-adjusted rates of hospitalization for asthma
than the state rate in 2003. Richmond City (40.6 per 10,000), Crater (28.0 per 10,000),
Cumberland Plateau (26.9 per 10,000), Southside (24.6 per 10,000), and Portsmouth (22.5 per
10,000) Health Districts had the highest rates of hospital discharge for asthma in Virginia (Figure
49).

Figure 49. Asthma Hospital Discharge Rates* (per 10,000) by Health District, Virginia, 2003




Source: Virginia Health Information Patient Level Data, 2003. *Rates are age-adjusted to the 2000 U.S. standard
population. Hospital discharges where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).




                                                                                                            47
 Asthma in Virginia, 2006

In 2004, Richmond City (33.4 per 10,000), Cumberland Plateau (29.2 per 10,000), Crater (27.4
per 10,000), Piedmont (24.4 per 10,000), and Portsmouth (24.1 per 10,000) Health Districts had
the highest rates of hospitalization for asthma and higher than the entire state as well (Figure
50).

Figure 50. Asthma Hospital Discharge Rates* (per 10,000) by Health District, Virginia, 2004




Source: Virginia Health Information Patient Level Data, 2004. *Rates are age-adjusted to the 2000 U.S. standard
population. Hospital discharges where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

Since Richmond City, Crater, and Cumberland Plateau Health Districts had the highest asthma
hospital discharge rates of all Health Districts in the state from 2002-2004, these Health Districts
could be targeted with intervention to reduce asthma hospitalization and to achieve the Healthy
People 2010 goal for asthma.




                                                                                                              48
 Asthma in Virginia, 2006

Cost of Asthma in Virginia
In the United States, direct and indirect economic costs for all forms of asthma total $14 billion,
including $9.4 billion in direct costs and $4.6 billion in indirect costs (missed school and
workdays). [30] Kevin Weiss, et al. estimated the cost for asthma hospital discharges was $6.2
billion in 1990.The cost now is more than doubled the cost in the 1990’s. See Appendix B for
additional data for cost and length of stay for asthma hospitalizations from 1999-2004.

          Table 5. Asthma Hospitalization Charges, by Primary Payor, Virginia, 2004
                               Number of          Total Charge      Percent of Total
                            Hospitalizations        (dollars)           Charges
        Payor
         Self-Pay                    530            3,899,392               4.0
         Private Insurance         3,894           32,783,331              33.9
         Medicaid                  2,041           17,614,310              18.2
         Medicare                  2,627           38,744,248              40.1
         Other                       368            3,558,413               3.7
        Total                       9460           96,599,694              100
      Source: Virginia Health Information Patient Level Data, 2004. Asthma hospitalization where
      the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

A primary payor is the major source from which hospitals anticipate to receive payment for
charges acquired from a hospitalization. The primary payor information in the VHI patient level
data set is divided into several categories. For this analysis, these were grouped into five
categories. They are self-pay, private insurance, Medicaid, Medicare, and other.

In 2004, Medicare was the primary payor for 40.1 percent of all asthma hospitalization charges
in Virginia, followed by private insurance, which was 34 percent of all charges. Medicaid was
liable for 18.2 percent and both self-pay and other methods of payment accounted for four
percent of all asthma hospital charges, with total charges being approximately 96 million dollars
(Table 5).




                                                                                                   49
 Asthma in Virginia, 2006

Cost for hospital services for asthma is one of the elements of direct medical expenses. Direct
medical expenses are comprised of ambulatory care visits, hospital outpatient and emergency
department services, physician visits, and prescribed drugs. Indirect medical expenses include
economic losses resulting from missed workdays or school, caregiver costs, travel cost, and
days with restricted activities. [30]

  Table 6. Length of Stay (LOS) and Charges for Asthma Hospitalization, Virginia, 1999-2004
                         1999       2000        2001      2002          2003         2004
                      (N=10,675) (N=9,617) (N=9,673) (N=9,107) (N=10,498) (N=9,460)
  Charges dollars)
    Mean                 5748       6133        6559      7467          8897        10211
    Median               3909       4147        4484      5027          5927         6738
  Total               61,357,832 58,981,046 63,448,010 68,007,638 93,402,906 96,599,694
  LOS (days)
    Mean                 3.35       3.33        3.24      3.32          3.51         3.61
    Median               3.00       2.00        2.00      2.00          3.00         3.00
  Total                 35788      32052       31298     30254         36896        34115
 Source: Virginia Health Information Patient Level Data, 1999-2004. Asthma hospitalization where
 the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

Table 6 shows that among Virginia residents, in 2004, there were 9,460 hospital discharges with
asthma as the primary diagnosis, resulting in 34,115 hospital stays and total charges of 96
million dollars. The total hospital charges for asthma hospitalizations have varied since 1999 and
increased 58 percent from 61.0 million in 1999 to 96.6 million in 2004. The average cost per
asthma hospitalization has increased 78 percent from $5,747 in 1999 to $10,211 in 2004.

In Virginia, the average length of stay has increased 8 percent from 3.3 days in 1999 to 3.6 days
in 2004 (Table 6). The national average length of stay was 3.2 days in 2004, slightly lower than
the Virginia estimate for the same year. In Virginia, the length of stay for females was 4.0 days,
compared to males with 3.6 days in 2004 (Table 20). Length of stay for females was higher than
males both in the U.S. (3.5 days versus 2.8 days) and in Virginia in 2004. White Virginians had a
longer length of stay than black Virginians (Table 20).




                                                                                                   50
 Asthma in Virginia, 2006

Between 1999 and 2004, the average cost of asthma hospitalization consistently increased with
age. In 2004, the average cost per asthma hospitalization for the age group of 0 to 4 years was
$5,380; the 65 years and older age group had an average charge of $14,982 (Figure 51).

     Figure 51. Average Charges per Asthma Hospitalization by Age, Virginia, 1999-2004
                                  $20,000
                                  $18,000
                                  $16,000                                                      0-4
                                                                                               5-14
              Average Charges




                                  $14,000
                                                                                               15-34
                                  $12,000
                                                                                               35-64
                                  $10,000                                                      65+
                                   $8,000
                                   $6,000
                                   $4,000
                                   $2,000
                                      $0
                                             1999   2000   2001   2002    2003     2004
             Source: Virginia Health Information Patient Level Data, 1999-2004. Asthma hospitalization
             where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

      Figure 52. Average Charges per Asthma Hospitalization by Sex, Virginia, 1999-2004
                                  16000

                                  14000
                                  12000
                Average Charges




                                  10000

                                   8000
                                   6000
                                                                                             Male
                                   4000
                                                                                             Female
                                   2000

                                      0
                                            1999    2000   2001    2002     2003      2004

             Source: Virginia Health Information Patient Level Data, 1999-2004. Asthma hospitalization
             where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

Figure 52 shows that from 1999 to 2004, females had consistently higher average charges per
asthma hospitalization compared to males. In 2004, the average cost for females was $11,097
compared to males at $8,783.




                                                                                                         51
    Asthma in Virginia, 2006

There were no similarities in ranking among Health Districts’ number of asthma hospitalizations
and the average charges for hospital stays in 2004. For example, Fairfax (ranked 1st of 35) and
Richmond (ranked 2nd of 35) Health Districts had the highest number of asthma discharges and
ranked lower (Fairfax ranked 12 of 35 and Richmond ranked 4 of 35) for average charges.
Hospitals in the Hanover8 Health District that had a relatively small number of asthma
discharges (31 of 35) ranked highest for average charges.

       Figure 53. Average Charges per Asthma Hospitalization by Health District, Virginia, 2004


                  Hanover                                                                  $17,900
             Chesterfield                                                               $17,332
                  Henrico                                                              $17,091
           Richm ond City                                                    $13,774
            Roanoke City                                                  $13,241
               Alexandria                                                $13,176
                    Crater                                              $12,817
                New River                                        $11,431
            Three Rivers                                        $11,316
                Alleghany                                     $10,960
    Cum berland Plateau                                    $10,371
                    Fairfax                              $10,012
                 Arlington                             $9,744
                Peninsula                              $9,629
           Mount Rogers                               $9,542
           Virginia Beach                            $9,335
             Portsm outh                            $9,289
                 Ham pton                          $9,054
                Piedm ont                        $8,658
     Rappahannock/Rapi                          $8,637
                 Loudoun                        $8,637
                   Norfolk                     $8,438
     Western Tidew ater                        $8,400
               Lenow isco                     $8,220
           Eastern Shore                     $8,096
           Prince William                    $7,989
                Southside                  $7,668
           Rappahannock                    $7,633
          Central Virginia                $7,434
             Chesapeake                 $7,145
          West Piedm ont                $7,072
      Thom as Jefferson               $6,682
     Pittsylvania/Danville          $6,318
              Lord Fairfax         $6,193
    Central Shenandoah           $5,756

                        $5,000     $7,000    $9,000     $11,000 $13,000 $15,000 $17,000 $19,000 $21,000 $23,000
                                                              Average Charges

Source: Virginia Health Information Patient Level Data, 2004. Asthma hospitalization where the primary diagnosis
was asthma (ICD-9-CM codes 493.0-493.9).




8
 Hanover Health District, located in the central region of the state, has been renamed Chickahominy Health District,
as of July 2006.


                                                                                                                  52
 Asthma in Virginia, 2006

Figure 54 shows that between 1999 and 2004 the average length of stay for an asthma
hospitalization generally increased among adults, aged 65 years and older, followed by 35-64
years. Children under 5 years of age had shorter lengths of stay compared to adults. In 2004,
adults, 65 years and older, had the longest average hospital stay of 5.6 days.

   Figure 54. Average Length of Stay for Asthma Hospitalization by Age, Virginia, 1999-2004
                                 8.00

                                 7.00                                                   0-4
                                                                                        5-14
                                 6.00
             Average LOS (days




                                                                                        15-34
                                 5.00                                                   35-64
                                                                                        65+
                                 4.00

                                 3.00

                                 2.00

                                 1.00

                                 0.00
                                        1999   2000   2001   2002   2003     2004

              Source: Virginia Health Information Patient Level Data, 1999-2004. Asthma hospitalization
              where the primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).

Nationally, the average length of stay for the 65 years and older age group was 4.8 days in
2004. The average length of stay in Virginia was higher than the U.S. among adults aged 65
years and older in 2004.




                                                                                                          53
    Asthma in Virginia, 2006

Average length of stay per asthma hospitalization varied within Virginia’s Health Districts9 in
2004. Roanoke City Health District had the highest average length of stay among Health
Districts in Virginia. Some of the Health Districts with a high number of discharges (Fairfax,
Richmond, Rappahannock, Prince William, Central Virginia, and Crater) had relatively lower
average lengths of stay (Figure 55). A number of Health Districts (Alleghany, Mount Rogers,
Eastern Shore, and Alexandria) with a relatively low number of discharges had higher average
lengths of stay (Figure 55).

    Figure 55. Average Length of Stay for Asthma Hospitalization by Health District, Virginia, 2004

               Roanoke City                                                                       5.22
                   Alleghany                                                                   4.99
                     Henrico                                                                  4.94
                     Hanover                                                               4.72
              Eastern Shore                                                             4.54
              Mount Rogers                                                           4.35
                  Alexandria                                                        4.27
                Chesterfield                                                     4.06
               Three Rivers                                                     3.89
                   New River                                                   3.86
       Cum berland Plateau                                                    3.86
                    Arlington                                                3.83
                       Fairfax                                               3.81
              Richm ond City                                               3.72
                       Crater                                             3.65
                   Southside                                            3.51
        Western Tidew ater                                              3.49
              Virginia Beach                                           3.43
                    Loudoun                                            3.43
                Chesapeake                                            3.36
             West Piedm ont                                          3.33
                   Peninsula                                         3.30
                    Ham pton                                         3.30
             Central Virginia                                       3.25
              Prince William                                       3.21
                 Lord Fairfax                                      3.21
     Rappahannock/Rapidan                                         3.14
                Portsm outh                                      3.07
                      Norfolk                                    3.07
       Central Shenandoah                                       3.05
              Rappahannock                                      3.01
                  Lenow isco                                   2.98
                   Piedm ont                                   2.97
        Pittsylvania/Danville                              2.71
         Thom as Jefferson                                2.65

                             0.00   1.00        2.00       3.00            4.00           5.00           6.00   7.00
                                                            Avg. LOS (days)


    Source: Virginia Health Information Patient Level Data, 2004. Asthma hospitalization where the primary diagnosis
    was asthma (ICD-9-CM codes 493.0-493.9).




9
 Hanover Health District, located in the central region of the state, has been renamed Chickahominy Health District,
as of July 2006.




                                                                                                                       54
 Asthma in Virginia, 2006

Asthma Deaths in Virginia
Asthma deaths are rare and preventable, however their occurrence indicates inadequate access
to health care or difficulties in self-management. About 4,500 individuals die from asthma
annually in the United States, an unacceptable number for an event that can be prevented. [31]
Well-managed asthma decreases symptoms and results in better quality of life. The elevated
risk of asthma death occurs due to failure to properly control the disease.

Asthma deaths are more likely to happen in females and blacks, resembling patterns in asthma
prevalence and hospitalization. These race and gender differences also persist nationally. In
2003, 4,099 people died due to asthma in the United States. The female death rate was 80
percent greater than the rate seen in males, and the age-adjusted death rate for asthma in the
black population was more than double the rate in the whites. In recent years, the number of
deaths due to asthma has continued to decline. The number of asthma deaths has decreased
by 12 percent since 1999. [32]

This component of the report addresses the information of asthma deaths in Virginia from 1999
to 2004. It includes the annual numbers and age-adjusted mortality rates due to asthma during
that period. The rates are age-adjusted to the 2000 U.S. standard population for valid
comparison between populations of different age distributions and the age-adjusted rates are
presented per 1,000,000 population.

Data from 1999 to 2004 were combined (unless otherwise noted) due to the small number of
asthma deaths and to obtain statistically reliable rates by age, sex, and race. The asthma
mortality rates were calculated using the number of asthma deaths over the six-year period as
numerator and population estimates from the Virginia annual population estimates, 1999-2004,
was used as the denominator multiplied by 1,000,000. In this report, an asthma death was
classified as a Virginia resident death record with asthma as the underlying cause of death.

Asthma mortality data were obtained from VDH, Division of Health Statistics. Virginia resident
deaths that occur within and outside the state are included in this report. Until 1998, asthma
death data were coded under the Ninth Revision of International Classification of Diseases (ICD)
with ICD-9 code of 493.0-493.9 as an underlying cause of death. ICD Revision 10 was
introduced in 1999 and therefore, ICD-10 asthma death diagnosis codes of J45 to J46 were
used to categorize asthma as an underlying cause of deaths from 1999-2004. Mortality rates for
demographic subgroups with a small number of asthma deaths (less than 20 deaths) were not
presented in this report because these rates were statistically unreliable. See Appendix B for
detailed data on asthma deaths from 1999-2004.




                                                                                             55
 Asthma in Virginia, 2006

In Virginia, from 1999-2004, there were 680 asthma deaths, with an average of 113 deaths per
year. Mortality from asthma in Virginia declined between 1999 and 2004, from 20.1 per
1,000,000 in 1999 to 12.5 per 1,000,000 in 2004, with a small peak in 2003 (Figure 56).
However, the average asthma mortality rate was 16.2 per million from 1999-2004 in Virginia.

            Figure 56. Asthma Mortality Rates* (per 1,000,000) Virginia, 1999-2004
                                 30.0

                                 25.0
            Rate per 1,000,000




                                        20.1    18.6
                                 20.0
                                                                        16.5
                                                        15.2   14.9
                                 15.0
                                                                                      12.5
                                 10.0

                                  5.0

                                  0.0
                                        1999   2000    2001    2002    2003        2004

           Source: VDH, Division of Health Statistics, 1999-2004. *Rates are age-adjusted to the
           2000 U.S. standard population. Asthma death where the underlying cause of death was
           asthma (ICD-10 codes J45-J46).

According to National Center for Health Statistics (NCHS), 4,099 asthma deaths occurred in the
United States and the age-adjusted asthma mortality rate was 14.0 per million in 2003. [33] In
Virginia, for the same year, the asthma mortality rate was 16.5 per million, which was higher
than the national rate.




                                                                                                   56
 Asthma in Virginia, 2006

The asthma mortality rate increases with age. In Virginia, from 1999 to 2004, the highest age
specific mortality rate was among adults aged 65 years and older, with 62.8 per 1,000,000
population, followed by adults aged 35-64 years at a rate of 16.8 per 1,000,000 population
(Figure 57). Reliable rates were not available for those under the age of 15 due to small (less
than 20) numbers of deaths. About half (45%) of all asthma deaths were for adults aged 65 and
older from 1999- 2004.

Figure 57. Asthma Mortality Rates* (per 1,000,000) by Age, Virginia, 1999-2004 (combined)10
                                    80.0

                                    70.0

                                    60.0
               Rate per 1,000,000




                                    50.0

                                    40.0

                                    30.0

                                    20.0

                                    10.0

                                     0.0
                                           0-4   5-14   15-34        35-64         65+

              Source: VDH, Division of Health Statistics, 1999-2004 (combined). *Rates are age-specific.
              +Rates are not shown if less than 20 asthma deaths were reported.
              Asthma death where the underlying cause of death was asthma (ICD-10 codes J45-J46).




10
  Due to small number of asthma deaths, findings from 1999 through 2004 were aggregated (unless otherwise
noted) to obtain the statistically reliable rates.




                                                                                                            57
 Asthma in Virginia, 2006

Figure 58 shows that Virginia females had a higher age-adjusted mortality rate due to asthma
from 1999 to 2004 (19.5 per 1,000,000 population) compared to males (12.0 per 1,000,000
population), reflecting the gender differences seen in Virginia current asthma prevalence and
asthma hospitalizations. According to national estimates, more females die from asthma than
males and women account for about 65 percent of asthma deaths overall. [34] In Virginia, 65.3
percent of females died from asthma compared to 34.7 percent of males between 1999 and
2004.
        Figure 58. Asthma Mortality Rates* (per 1,000,000) by Sex, Virginia, 1999- 2004
                                 30.0

                                 25.0
            Rate per 1,000,000




                                                                       19.5
                                 20.0

                                 15.0
                                        12.0
                                 10.0

                                  5.0

                                  0.0
                                        Male                         Female
            Source: VDH, Division for Health Statistics, 1999-2004. *Rates are age-adjusted to
            the 2000 U.S. standard population. Asthma death where the underlying cause of
            death was asthma (ICD-10 codes J45-J46).

       Figure 59. Asthma Mortality Rates* (per 1,000,000) by Race, Virginia, 1999- 2004
                                 50.0

                                 40.0
                                                                       35.5
            Rate per 1,000,000




                                 30.0

                                 20.0
                                         11.8
                                 10.0

                                  0.0
                                        White                         Black
            Source: VDH, Division for Health Statistics, 1999-2004. *Rates are age-adjusted to the
            2000 U.S. standard population. Asthma death where the underlying cause of death
            was asthma (ICD-10 codes J45-J46).

Figure 59 indicate, from 1999 to 2004, the age-adjusted asthma mortality rate was three times
higher for black Virginians (35.5 per 1,000,000 population) than the rate for whites (11.8 per
1,000,000 population). The rate for people of other race groups was not available due to the
small number of deaths during that period.



                                                                                                     58
 Asthma in Virginia, 2006

Between 1999 and 2004, in Virginia, the asthma mortality rate was over two times higher among
females aged 65 years and older (80.2 per 1,000,000 population) compared to males aged 65
years and older (37.8 per 1,000,000 population). The majority of asthma deaths occurred in
elderly adults (Figure 60). The reliable rates were not available for those under the age of 15
years due to the small number of deaths.

   Figure 60. Asthma Mortality Rates* (per 1,000,000) by Sex and Age, Virginia, 1999-2004
                                      100.0
                                       90.0
                                       80.0
            Rate per 1,000,000




                                       70.0
                                       60.0
                                       50.0
                                       40.0                                            Male
                                       30.0                                            Female
                                       20.0
                                       10.0
                                        0.0
                                              0-4   5-14   15 - 34   35 - 64    65+

            Source: VDH, Division for Health Statistics, 1999-2004. *Rates are age-specific.
            +Rates are not shown if less than 20 asthma deaths were reported. Asthma death
            where the underlying cause of death was asthma (ICD-10 codes J45-J46).

Black Virginians, aged 65 years and older, experienced the highest asthma mortality rate from
1999 to 2004. Overall, blacks had higher asthma mortality rates than whites across all age
groups (Figure 61). Reliable asthma mortality rates were not available in other race categories,
for those under the age of 15, and whites 15-34 years, due to the small number of deaths.

   Figure 61. Asthma Mortality Rates* (per 1,000,000) by Race and Age, Virginia, 1999-2004
                                      120.0
                                      110.0
                                      100.0
                                       90.0
                 Rate per 1,000,000




                                       80.0
                                       70.0
                                       60.0
                                       50.0
                                       40.0                                            White
                                       30.0
                                                                                       Black
                                       20.0
                                       10.0
                                        0.0
                                              0-4   5-14   15 - 34   35 - 64     65+
            Source: VDH, Division for Health Statistics, 1999-2004. * Rates are age-specific.
            +Rates are not shown if less than 20 asthma deaths were reported.
            Asthma death where the underlying cause of death was asthma (ICD-10 codes J45-J46).

In 2003, according to the NCHS, the age-adjusted mortality rate for asthma in blacks (3.2 per
100,000) in the U.S. was also higher than in whites (1.1 per 100,000). [33]


                                                                                                  59
 Asthma in Virginia, 2006

Twelve of the 35 Health Districts had more than 20 asthma deaths between 1999 and 2004. The
rest of the Health Districts had less than 20 deaths for the entire period. This makes it
impossible to calculate the asthma mortality rate by Health District with sufficient reliability. The
Richmond City Health District had the highest number of deaths due to asthma in the six-year
period followed by Fairfax, Norfolk City, and Henrico. However, these Health Districts have a
high population number.

The Richmond City Health District, with the highest number of asthma deaths, also had the
highest rate of asthma hospital discharges between 2002 and 2004 and ranked third in current
asthma prevalence rate (2004). Very surprisingly, Lenowisco Health District, with the highest
current asthma prevalence rate (11.7%) and high hospital discharge rate in 2004 (18.6 per
10,000) had small number of deaths over the six-year period. See detailed data table in
Appendix B for asthma deaths.

 Table 7. Asthma Mortality Rates* (per 1,000,000) Virginia, 1999-2004 (combined) and Healthy
                               People 2010 Objectives, by Age
                                    Mortality Rate        US Healthy People
                                 Virginia, 1999-2004         2010 Objective
               Age (years
                  0-4                      +                      1.0
                  5-14                     +                      1.0
                  15-34                   4.7                     2.0
                  35-64                   16.8                    9.0
                  65+                     62.8                    60.0
                Source: VDH, Division for Health Statistics, 1999-2004.
                U.S. data: U.S. Department of Health and Human Services, 2000.
                http://www.healthypeople.gov. *Rates are age-specific.
                +Rates are not shown if less than 20 asthma deaths were reported. Asthma death
                where the underlying cause of death was asthma (ICD-10 codes J45-J46).

To reduce mortality from asthma, Healthy People 2010 identified an objective to reduce asthma
deaths to one death per million among under 5 and 5-14 year olds; two per million among 15-34
year olds; nine deaths per million among 35-64 year olds; and sixty per million among those 65
years and older. [25] The age-specific mortality rates for Virginia residents were calculated
across all age groups. However, rates are not shown for 0-4 and 5-14 years of age due to the
small numbers of deaths (<20).

From 1999-2004, 45 percent of all asthma deaths occurred among adults aged 65 years and
older in Virginia. The asthma mortality rates for Virginia residents, aged 15-34, 35-64, and 65
years and older, were higher than the Healthy People 2010 target objective for these age groups
(Table 7).




                                                                                                  60
 Asthma in Virginia, 2006

Asthma in School
According to CDC, about three out of 30 children in one classroom are likely to have asthma.
School aged children spend a significant amount of time in school. Schools work to manage and
control asthma by adopting policies and procedures, and coordinating student services to better
care for students with asthma.

Nationally, in 2002, 14.7 million school days were missed due to asthma. The estimated cost of
treating asthma in children less than 18 years of age was 3.2 billion dollars per year. Among
children under 15 years of age, asthma is the third leading cause of hospitalizations in the U.S.
[35] According to 2003 Virginia BRFSS data, 12.9 percent of adults reported that they had at
least one child in their household, aged 0-17 years, that had ever been diagnosed with asthma.

The CDC published a document called “Strategies for Addressing Asthma Within a Coordinated
School Health Program” that offers distinct suggestions for schools to improve the health and
school attendance of students with asthma. The six strategies for addressing asthma within a
coordinated school health program are:

   1. Establish management and support systems for asthma- friendly schools,

   2. Provide appropriate school health and mental health services system for students with
      asthma,

   3. Provide asthma education and awareness programs for students and school staff,

   4. Provide a safe and healthy school enjoinment to reduce asthma triggers,

   5. Provide safe, enjoyable physical education and activity opportunities for students with
      asthma,

   6. Coordinate community efforts to better manage asthma symptoms and reduce school
      absences among students with asthma. [35]




                                                                                              61
 Asthma in Virginia, 2006

Asthma Management Activities in Middle and High Schools
Since 2000, the School Health Education Profile (SHEP) survey has been administered in
Virginia schools. The survey was developed by CDC to collect information about health
education in Virginia public schools in grades six to twelve. The SHEP survey has been
conducted every other year. The survey results are presented in table 8.

    Table 8. Percent of School-Based Asthma Management Activities Among Public Schools,
                         Grades 6, and Higher, Virginia, 2002 and 2004
                          Activities                                Percent of Schools
                                                                  2002            2004
 Encourage full participation in physical education and          96               98
 physical activity when students with asthma are doing well

 Assure immediate access to medications as prescribed by         92               94
 a physician and approved by parents

 Identify and track all student with asthma                      88               94

 Provide modified physical education and physical activities     84               90
 as indicated by the student's Asthma Action Plan

 Obtain and use an Asthma Action Plan for all students with      69               71
 asthma

 Provide a full-time registered nurse, all day, everyday         60               60

 Educate students with asthma about asthma management            60               60

 Educate school staff about asthma                               59               66

 Provide intensive case management for students with             43               44
 asthma who are absent 10 days or more per year

 Teach asthma awareness to all students in at least one          33               36
 grade
Source: School Health Profile Survey, Virginia, 2002 and 2004.

Approximately 90 percent of schools conducted four out of 10 asthma management activities, an
increase from two in 10 from 2002. In the 2004 survey, 36 percent of schools taught asthma
awareness to all students in at least one grade level. Less than half of the schools provided
intensive case management for students with asthma who were absent 10 days or more during
the school year.




                                                                                          62
 Asthma in Virginia, 2006

Work-Related Asthma
Work-related factors play a significant role in developing respiratory disease and symptoms.
According to the National Institute for Occupational Safety and Health (NIOSH) work-related
asthma (WRA) is defined as a reversible, generalized airway narrowing as a result of exposure
to airborne dust, gases, vapors, or fumes in the work environment. A current announcement
from the American Thoracic Society estimated that 15 percent of asthma in the adult population
is attributable to occupational exposure. However, most of the cases are either not recognized
as work-related or not reported as such. [37]

Work-related asthma is defined as a lung disorder characterized by breathing difficulty,
wheezing, and cough caused by work exposure, and aggravated by work or the work
environment. Clinical data are important in defining relationships between the suspect exposures
and the patient’s symptoms. Asthma management at work needs a comprehensive move toward
involving patients and their families, health providers, employers, and governmental agencies.
[38]

In Virginia, work-related asthma data are not currently available.




                                                                                             63
 Asthma in Virginia, 2006

Conclusions
Asthma is a chronic disease affecting adults and children, and a growing public health problem
in the U.S. Asthma continues to affect a large proportion of population in Virginia. According to
the 2004 BRFSS, 7.3 percent of Virginia adults had current asthma and 13 percent of adults had
lifetime asthma. Fifty-six percent of adults with current asthma reported having a routine
checkup in the past 12 months, 70 percent reported taking asthma medication at least once a
day in the past 30 days, and 35 percent reported that they were unable to work or carry out their
usual activities in the past year. Improvement is needed in managing asthma in Virginia within
NHLBI guidelines.

Poor asthma management results in increased asthma hospitalizations, which are expensive in
terms of direct and indirect costs. In 2004, the average charges for an asthma hospitalization
were $10,211 with average length of stay of 3.6 days. The total asthma hospitalization charges
among Virginians were $96.6 million in 2004. In Virginia, asthma hospitalization rates and
mortality rates had decreased over the past six years, however, these rates did not meet
Healthy People 2010 targets in any age group.

Only 36 percent of schools teach asthma awareness to all students in at least one grade and
less than half (44%) provide intensive case management for students with asthma who are
absent 10 days or more in the school year. Results from these data show that improving asthma
management in schools is one of the potential interventions statewide.

While asthma has an effect on the entire population of Virginia, asthma prevalence,
hospitalization, and mortality are concentrated in certain population subgroups and some
specific localities in Virginia. Therefore, there is an opportunity for improvement of asthma
management in relation to proper diagnosis, enhanced regular care, proper medication,
reducing exposure to triggers, and training health care providers. Asthma education and focused
interventions in the direction of improving these proceedings, with a particular importance in
groups disproportionately affected with asthma, will be required to lower asthma’s burden in
Virginia.

Future asthma surveillance reports will contain data from existing sources and from additional
sources cultivated over the next few years. The most current and comprehensive representation
of asthma in Virginia is presented. This report can assist in directing and monitoring trends of
asthma over time and will help in evaluation to reduce the burden of asthma across the state.
Critical data gaps remain for asthma. For example, ED visits, outpatient, Medicaid, and work-
related asthma data are missing. Also, there are many missed school and workdays caused by
asthma, but no data are available to track these burdens for people living with asthma. VACP is
working with other data sources to expand surveillance activity according to its work plan to
track work-related asthma, claims on Medicaid, and cost and utilization services for state
employees with asthma. These efforts will boost asthma surveillance measures and provide
opportunities to increase the understanding of asthma in Virginia.




                                                                                              64
 Asthma in Virginia, 2006

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2. Asthma overview. Asthma and Allergy Foundation of America. Available at:
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3. NAEPP Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma.
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4. Centers for Disease Control and Prevention. Adult Asthma Data: Prevalence Tables and
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5. National Heart, Lung, and Blood Institute. Practical Guide for the Diagnosis and Management
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6. National Heart, Lung, and Blood Institute. Key Clinical Activities for Quality Asthma Care.
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7. Virginia Department of Health. Chronic Disease Prevention and Control. Virginia Asthma
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8. Virginia Asthma Coalition. Available at: http://www.virginiaasthmacoalition.org

9. Cassol V, Rizzato TM Teche SP, Basso DF, Centenaro DF, Maldonado M, Moraes EZ,
Hirakata VN, Sole D, Menna-Barreto SS. Obesity and its relationship with asthma prevalence
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10. Ford ES, Mannino DM. Time trends in obesity among adults with asthma in the
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12. Ford ES, Mannino DM, Williams SG. Asthma and Influenza Vaccination: Findings From the
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13. Bohadana AB, Hannhart B, Teculescu DB. Nocturnal worsening of asthma and sleep-
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14. Janson C, Gislason T, Boman G, Hetta J, Roos BE. Sleep disturbances in patients with
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15. Ait-Khaled N, Enarson DA. Management of asthma: the essentials of good clinical practice.
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16. Pollart SM, Chapman MD, Fiocco GP, Rose G, Platts-Mills TA. Epidemiology of acute
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18. Wong GW, von Mutius E, Douwes J, Pearce N. Environmental determinants associated with
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20. Kumar RK. Bronchial asthma: recent advances. Indian J Pediatr. 2000 Apr; 67(4): 293-8.

21. Centers for Disease Control and Prevention. Asthma's Impact on Children and Adolescents.
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22. Bloom B, Dey AN. Summary Health Statistics for U.S. Children: National Health Interview
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23. DeFrances CJ, Podgornik MN. 2004 National Hospital Discharge Survey. Advance data from
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24. CSTE Environmental and Chronic Disease Committees. Asthma Surveillance and Case
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25. U.S. Department of Health and Human Services. Healthy People 2010: Volume1&11
(second edition). Understanding and Improving Health. Objectives for Improving Health (part B:
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26. Schatz M, Clark S, Emond JA, Schreiber D, Camargo CA Jr. Sex differences among children
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29. Minnesota Department of Health. Asthma Hospitalizations peak in September Fact Sheet.
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30. Smith DH, Malone DC, Lawson KA, Okamoto LJ, Battista C, Saunders WB. A national
estimate of the economic costs of asthma. Am J Respir Crit Care Med. 1997 Sep; 156(3 Pt 1):
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32. American Lung Association. Data & Statistics. Trends in Asthma Morbidity and Mortality,
July 2006.

33. Hoyert DL, Heron MP, Murphy SL, Kung H. Deaths: Final Data for 2003. National vital
statistics reports; vol 54 no 13. Hyattsville, MD: National Center for Health Statistics. 2006.

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Statistics, Centers for Disease Control and Prevention.

35. Addressing Asthma in Schools. Division of Adolescent and School Health. National Center
for Chronic Disease Prevention and Health Promotion. Available at:
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36. Child and Adolescent Health Measurement Initiative (2005). National Children’s Health, Data
Resource Center on Child and Adolescent Health. Available at: www.nschdata.org

37. NIOSH Topic: Asthma and Allergies: Prevention of OA: Primer | CDC/NIOSH. Sep13, 2005.
Available at: http://www.cdc.gov/niosh/topics/asthma/OccAsthmaPrevention-primer.html

38. American Thoracic Society 2004. Guidelines for assessing and managing asthma risk at
work, school, and recreation. Am J Respir Crit Care Med 169:873–881.

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Washington State Department of Health. Available at:
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40. S Holtby, E Zahnd, N Lordi, C McCain, YJ Chia, JH Kurata. Health of California’s Adults,
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                                                                                                  67
 Asthma in Virginia, 2006

Acronyms
AAFA       Asthma and Allergy Foundation of America
ALAV       The American Lung Association of Virginia
BRFSS      Behavioral Risk Factor Surveillance System
BMI        Body Mass Index
CDC        Centers for Disease Control and Prevention
COPD       Chronic Obstructive Pulmonary Disease
CSTE       The Council of State and Territorial Epidemiologists
CI         Confidence Interval
DCDPC      Division of Chronic Disease Prevention and Control
ED         Emergency Department
HD         Health District
LAC        The local asthma coalitions
NHLBI      National Heart, Lung, and Blood Institute
NAEPP      National Asthma Education and Prevention Program
NIOSH      The National Institute for Occupational Safety and Health
NCEH       National Center for Environmental Health
NCHS       National Center for Health Statistics
NHIS       National Health Interview Survey
NSCH       National Survey of Children’s Health
NHDS       National Hospital Discharge Survey
SHEP       School Health Education Profile Survey
VDH        Virginia Department of Health
VACP       Virginia Asthma Control Project
VAC        Virginia Asthma Coalition
VHI        Virginia Health Information, Inc.
VCHETRC    Virginia Comprehensive Health Education, Training, and Resource Center
VDOE       Virginia Department of Education
WRA        Work-related Asthma




                                                                                    68
 Asthma in Virginia, 2006

Appendix A. Technical Notes

National comparisons

In this report, Virginia rates are compared to rates for overall U.S. population. Asthma related
objectives from Healthy People 2010 are compared to Virginia rates where appropriate.

Prevalence

Prevalence represents the proportion of individuals in a population who are affected by a
disease or condition at a specific time. The prevalence rate is calculated by dividing the number
of existing cases with a disease or condition at a specific time by the total population at risk in
that period. It is often multiplied by 100 and articulated as a percent. In this report, prevalence
estimate result from the Virginia BRFSS and SHEP.

Current Asthma Prevalence- Refers to the proportion of individuals who currently have asthma

Lifetime Asthma Prevalence- Refers to the proportion of individuals who have ever been
diagnosed with asthma at some point of their lifetime.

Confidence Interval

A confidence interval (CI) is a range of values that is normally used to describe the uncertainty
around a point estimate of a quantity. Therefore, confidence intervals are a measure of the
variability in the data. Confidence intervals provide a means of assessing and reporting the
precision of a point estimate, such as a mortality or hospitalization rate or a frequency of
reported behaviors. In the particular case of sample surveys, such as BRFSS, confidence
intervals also account for the difference between a sample from a population and the population
itself. When confidence intervals are used to describe health data such as prevalence or
mortality rates, confidence levels of 95 percent are generally used. Confidence intervals are
sometime used as a test of significance. [39]

For example, among Virginia adults, the estimated prevalence of current asthma is 7.3 percent,
with a 95 percent confidence interval of 6.5 percent to 8.2 percent; we are 95 percent confident
that the true prevalence in the population is no less than 6.5 percent and no greater than 8.2
percent. Confidence intervals are sometime used as a test of significance. CI is presented only
for asthma prevalence section for this report and can be found in Appendix B, in the detailed
data tables, usually next to the point estimates, as lower bound and upper bound.




                                                                                                69
 Asthma in Virginia, 2006

Statistical Significance

Confidence intervals give an easy way to determine if differences are statistically significant
among groups. [40] In the asthma prevalence section of this report, the point estimates for
different variables measured are considered statistically significant if their confidence intervals
did not overlap. However, if the confidence intervals do overlap, the difference between the two
percents is not statistically significant.

For example, using the prevalence of current asthma among adults by sex in 2004 (Table 9), if
Virginia males are compared with Virginia females, the current asthma prevalence rate appears
to be different (4.5% versus 10%). The confidence interval for males is (3.5-5.4) while the
confidence interval for females is (8.7-11.4). From these two confidence intervals, we can see
that the two intervals did not overlap. Therefore, we concluded that the differences in the current
asthma prevalence rate between males and females in Virginia are significant. In another words,
we can state that, in 2004, in Virginia, the current asthma prevalence rate was significantly
higher for females than males. Unless specified in the text, only statistically significant
differences between groups are referred to as “significantly” in the prevalence section of this
report.

Test of independence was used to produce p-value, which produces chi-square and likelihood
ratio tests of the hypothesis that a row and column variable are independent. The standard used
to assess the significance of a statistical test is p-value equal to 0.05. A p-value less than or
equal to 0.05 indicates that there is at most a 5 percent chance of observing a difference
between the groups by chance alone. [41] We used likelihood ratio to determine the significant
relationship in the asthma prevalence measure between groups.

Rate

A rate is a measure of the frequency of an event per population unit along with some
specification of time. The use of rates, rather than raw numbers, is important for comparison
among populations, since the number of events depends, in part, on the size of the population.
[39]

Crude Rate

Dividing the total number of events in a specified period by the total number of individuals in the
population who are at risk for these events and multiplying by a constant, such as 1,000 or
100,000, calculate a crude rate. Crude rates are computed, when a summary measure is
needed and not required to adjust for age. [39]

Age-specific Rates

An age-specific rate is a rate in which the number of events and population at risk are restricted
to an age group (e.g.), hospital discharge rates for people age 65 and older; death rate for
people age 45 to 64. [39]




                                                                                                70
 Asthma in Virginia, 2006

Age Adjustment of Rates

Age adjustment is a statistical procedure applied to rates of hospitalization, death, or disease. It
is used to compare risks of two or more populations at one point in time or one population at two
or more points in time. Age-adjusted rates are calculated by the direct method by applying age-
specific rates in a population of interest to a standardized age distribution in order to remove
differences in observed rates that result from age differences in population composition. Age-
adjusted rates should be viewed as relative indexes rather than actual measures of risk. [41] In
this report, both crude rates and age-adjusted rates are presented. To eliminate the difference in
observed rates across the different age group, rates were adjusted by means of direct method
and the 2000 U.S. standard population.

Numerators for Rate

Virginia residents only are included as numerators for rate calculations in this report. VHI
collects data only on hospital discharge in Virginia and does not track Virginia residents
hospitalized due to asthma outside the state and ED visits of Virginia residents. VDH, Division of
Health Statistics tracks the resident deaths in and out-of-state.

Denominators for Rate

In this report, population estimates were taken from Virginia annual population estimates, 1999-
2004 as denominators for calculating asthma hospitalization and mortality rates. The hospital
discharge rate is calculated per 10,000 population and mortality rate is calculated per 1,000,000
population.

Standard population

The standard population refers to the choice of populations used in developing age-adjusted
rates. [39]

Data Suppression

According to CDC’s Asthma Surveillance Fact Sheet, data are suppressed in this report so that
the presented rates are reliable. For demographic subgroups where there is less than or equal
to 20 asthma hospitalizations or asthma deaths, the rates are not presented.




                                                                                                 71
 Asthma in Virginia, 2006

Appendix B. Detailed Data Tables
 Table 9. Current Asthma Among Adults, by Demographic Subgroup, Virginia and U.S., 2004
                                     Virginia                   United States
                            Percent         95%CI¤        Percent         95%CI¤
   Age (years)
    18-24                     5.1           (2.7-7.6)       9.0           (8.3-9.8)
    25-34                     7.0           (5.0-9.0)       7.7           (7.2-8.1)
    35-44                     8.2          (6.3-10.1)       7.7           (7.3-8.1)
    45-54                     7.3           (5.5-9.0)       8.4           (8.0-8.9)
    55-64                     7.9          (5.8-10.0)       9.1           (8.6-9.5)
    65+                       8.1          (6.0-10.1)       7.4           (7.1-7.8)

   Sex
    Male                              4.5             (3.5-5.4)             6.1             (5.8-6.4)
    Female                           10.0            (8.7-11.4)            10.0            (9.7-10.3)

   Race/Ethnicity
    White                             7.3             (6.3-8.3)             8.2            (8.0-8.4)
    Black                             7.9            (5.8-10.1)             9.1            (8.4-9.7)
    Other                             4.8              (1.4-8.1)            8.0            (6.9-9.0)
    Multiracial                      11.9            (6.1-17.8)            14.0           (11.6-16.4)
    Hispanic                          5.1             (2.4-7.8)             6.2            (5.5-6.9)

   Income
     Less than $15,000               14.5           (10.4-18.5)            11.1           (10.4-11.8)
     $15,000-$24,999                  9.6            (7.3-11.9)             9.2            (8.7-9.7)
     $25,000-$49,999                  7.1             (5.6-8.7)             7.7            (7.4-8.1)
     $50,000-$74,999                  5.7             (3.8-7.6)             7.5            (7.0-8.0)
     $75,000or more                   6.0             (4.4-7.7)             6.9            (6.5-7.3)

   Education
    Less than HS                     11.9            (9.0-14.7)             9.7            (9.0-10.3)
    HS graduate                       7.3             (5.7-8.8)             7.7             (7.4-8.0)
    Some College                      6.6             (5.0-8.3)             8.7             (8.3-9.1)
    College graduate                  6.5             (5.2-7.9)             7.4             (7.1-7.7)
  Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
  U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System.
  http://www.cdc.gov/asthma/brfss/04/brfssdata.htm
  ¤CI – Confidence Interval (is a range of values within which there is a 95% chance that the true
  prevalence estimate lies).




                                                                                                        72
Asthma in Virginia, 2006

Table 10. Lifetime Asthma Among Adults, by Demographic Subgroup, Virginia and U.S., 2004
                                  Virginia                     United States
                          Percent          95%CI¤        Percent            95%CI¤
  Age (years)
   18-24                   18.8          (13.9-24.9)       17.4           (16.4-18.4)
   25-34                   13.4          (10.8-16.5)       13.7           (13.1-14.3)
   35-44                   12.3          (10.2-14.8)       12.4           (11.9-12.9)
   45-54                   11.9           (9.8-14.3)       13.1           (12.6-13.7)
   55-64                   12.5          (10.0-15.5)       13.7           (13.1-14.2)
   65+                     12.1           (9.8-14.8)       10.9           (10.5-11.4)

  Sex
   Male                           11.7              (9.9-13.7)              11.6             (11.2-12.0)
   Female                         14.8             (13.2-16.4)              14.9             (14.6-15.2)

  Race/Ethnicity
   White                          13.0             (11.6-14.6)              13.4             (13.1-13.7)
   Black                          16.2             (13.1-19.9)              14.6             (13.8-15.4)
   Other                           9.8              (5.3-17.3)              13.6             (12.2-15.1)
   Multiracial                    18.5             (12.5-26.5)              20.8             (18.2-23.5)
   Hispanic                        7.6              (4.7-12.1)              11.2             (10.2-12.1)

  Income
    Less than $15,000             20.0             (15.5-25.6)              16.2             (15.3-17.1)
    $15,000-$24,999               16.0             (12.9-19.6)              14.2             (13.6-14.8)
    $25,000-$49,999               12.3             (10.2-14.8)              12.9             (12.4-13.4)
    $50,000-$74,999               11.3              (8.7-14.5)              12.8             (12.1-13.4)
    $75,000or more                12.4             (10.2-15.0)              12.2             (11.7-12.7)

  Education
   Less than HS                   17.9             (14.5-21.9)              14.2             (13.4-15.0)
   HS graduate                    12.2             (10.3-14.3)              12.5             (12.0-12.9)
   Some College                   14.0             (11.3-17.2)              14.7             (14.1-15.2)
   College graduate               12.2             (10.4-14.2)              12.7             (12.3-13.1)
Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
U.S. data: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System.
http://www.cdc.gov/asthma/brfss/04/brfssdata.htm
¤CI -Confidence Interval (is a range of values within which there is a 95% chance that the true prevalence
estimate lies).




                                                                                                             73
 Asthma in Virginia, 2006

Table 11. Percentage of Adults with Behavioral Risk Factors by Current Asthma Status, Virginia,
                                            2004
                                           Current Asthma              No Asthma
                                        Percent       95%CI¤      Percent     95%CI¤
       Smoking Status
        Current Smokers                  24.5       (19.9-29.7)     20.5    (19.0-22.1)
        Non-smokers                      75.5       (70.3-80.1)     79.5    (77.9-81.0)

       Weight Status
        Not overweight/Obese                     33.3        (27.7-39.3)         40.5      (38.5-42.5)
        Overweight                               32.4        (27.1-38.1)         37.3      (35.4-39.3)
        Obese                                    34.4        (29.0-40.1)         22.2      (20.6-23.9)

       General Health Status
        Excellent/Very Good                      38.3        (32.7-44.2)         60.7      (58.7-62.6)
        Good                                     33.6        (28.5-39.1)         27.9      (26.1-29.8)
        Fair/Poor                                28.2        (23.5-33.3)         11.4      (10.4-12.5)

       Influenza Vaccination Status
         Vaccinated                              47.5        (41.9-53.3)         34.1      (32.3-36.1)
         Not-Vaccinated                          52.5        (46.7-58.1)         65.9      (64.0-67.7)

       Health Insurance Status
        Insured                                  87.5        (83.7-90.5)         85.7      (84.1-87.1)
        Uninsured                                12.5         (9.5-16.3)         14.3      (12.9-15.9)
     Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
     ¤CI – Confidence Interval (is a range of values within which there is a 95% chance that the true
     prevalence estimate lies).




                                                                                                         74
Asthma in Virginia, 2006

        Table 12. Current Asthma Among Adults, by Health District, Virginia, 2004
                                                                    Estimated
                                                               Number of People
                                   Percent        95%CI¤
                                                                   with Current
                                                                     Asthma
       Health District

         Alexandria                           6.2          (3.3-11.3)            4,876
         Alleghany                            3.4           (1.5-7.8)            4,154
         Arlington                           10.9          (6.9-17.0)            13,834
         Central Shenandoah                   8.4          (5.0-13.8)            22,755
         Central Virginia                     8.1          (4.5-14.2)            16,441
         Chesapeake                          11.7          (6.2-21.3)            15,996
         Chesterfield                         4.0           (2.0-7.9)            11,555
         Crater                               8.7          (4.8-15.5)            9,391
         Cumberland Plateau                   8.3          (4.7-14.1)            9,223
         Eastern Shore                        6.8          (3.6-12.6)            2,757
         Fairfax                              3.5           (1.7-7.3)            24,020
         Hampton                              7.4          (4.0-13.3)            7,405
         Hanover                             10.4          (6.3-16.8)            12,011
         Henrico                              5.9          (3.1-11.0)            12,758
         Lenowisco                           11.7          (7.4-18.1)            9,297
         Lord Fairfax                         8.9          (5.3-14.6)            15,315
         Loudoun                              7.1          (4.1-11.9)            9,128
         Mount Rogers                         9.5          (5.3-16.3)            17,282
         New Rivers                           3.5           (1.6-7.7)            4,196
         Norfolk City                        10.4          (5.9-17.9)            13,941
         Peninsula                            9.7          (5.1-17.7)            21,333
         Piedmont                             9.7          (5.0-18.1)            7,852
         Pittsylvania/Danville               10.4          (6.2-16.7)            8,647
         Portsmouth                           9.4          (5.5-15.7)            9,638
         Prince William                       6.9          (3.7-12.6)            18,328
         Rappahannock                         7.8          (4.3-13.8)            16,185
         Rappahannock/Rapidan                 8.1          (4.7-13.7)            9,439
         Richmond City                       10.8          (6.8-16.7)            15,807
         Roanoke City                         8.0          (4.3-14.3)            6,463
         Southside                            9.4          (5.7-15.2)            7,141
         Thomas Jefferson                     8.4          (4.6-14.8)            13,158
         Three Rivers                         7.8          (4.2-14.1)            9,931
         Virginia Beach                       7.1          (3.9-12.4)            21,865
         West Piedmont                        6.9          (3.6-12.8)            9,116
         Western Tidewater                    1.2           (0.2-6.3)            1,130
      Source: Virginia Behavioral Risk Factor Surveillance System, 2004. Percentages are weighted.
      ¤CI– Confidence Interval (is a range of values within which there is a 95% chance that the
       true prevalence estimate lies).



                                                                                                     75
Asthma in Virginia, 2006

Table 13. Asthma Management and Control Among Adults with Current Asthma, Virginia, 2003-
                                  2004 (combined)
                       Asthma Attack,      Activity Limitation,    Sleeping Difficulty,
                       Past 12 Months       Past 12 Months            Past 30 Days

                                Percent 95%CI¤               Percent 95%CI¤              Percent 95%CI¤
 Overall Virginia               50.6 (46.0-44.8)             34.7 (30.4-39.2)            47.7 (42.6-52.9)

 Age (years)
  18-24                         55.1 (39.7-69.5)             38.8 (24.8-54.9)            35.2 (20.6-53.3)*
  25-34                         53.2 (42.2-63.9)             33.6 (23.9-45.0)            50.0 (38.1-62.0)
  35-44                         57.4 (46.4-67.7)             40.0 (30.1-50.7)            59.3 (47.6-70.0)
  45-54                         49.9 (41.1-58.7)             37.1 (29.0-46.0)            50.3 (40.0-60.6)
  55-64                         48.2 (38.2-58.3)             30.0 (21.8-39.8)            52.7 (41.3-63.9)
  65+                           38.6 (29.4-48.6)             25.2 (17.1-35.5)            31.5 (21.7-43.2)

 Sex
  Male                          38.9 (31.5-46.9)             30.9 (23.8-39.1)             46.6 (37.4-56.1)
  Female                        56.3 (50.6-61.9)             36.5 (31.3-42.2)             48.2 (42.1-54.4)

 Race/Ethnicity
  White                         51.8 (46.5-57.2)             34.3 (29.1-39.8)            43.5 (37.5-49.8)
  Black                         43.9 (34.4-53.8)             37.4 (28.4-47.4)            52.4 (40.6-64.0)
  Other                         69.5 (45.1-86.3)*             17.7 (6.1-41.4)*           51.1 (24.0-77.6)*
  Multiracial                   44.8 (24.5-67.1)             30.2 (15.1-51.2)*           70.9 (52.1-84.6)*
  Hispanic                      61.0 (38.0-79.9)*            46.0 (24.1-69.6)*           65.1 (35.3-86.5)*

 Income
   Less than $15,000            59.4 (48.4-69.5)             46.4 (35.6-57.5)             56.5 (44.5-67.9)
   $15,000-$24,999              53.8 (44.0-63.3)             38.9 (29.8-48.9)             59.1 (47.4-70.0)
   $25,000-$49,999              55.8 (47.6-63.8)             38.3 (30.4-47.0)             48.8 (38.8-58.9)
   $50,000-$74,999              52.0 (40.2-63.5)             25.6 (16.7-37.1)             42.6 (29.3-57.2)
   $75,000or more               42.9 (31.8-54.8)             27.9 (18.2-40.1)             31.5 (20.8-44.6)

 Education
  Less than HS                  53.1 (43.9-62.1)             45.8 (36.1-55.7)             51.3 (40.4-62.0)
  HS graduate                   43.3 (34.6-52.4)             29.8 (22.6-38.2)             53.8 (44.2-63.2)
  Some College                  55.4 (46.5-64.0)             38.0 (29.5-47.4)             41.5 (31.8-52.0)
  College graduate              52.1 (43.9-60.2)             31.0 (23.5-39.8)             44.5 (34.7-54.8)
Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004. Percentages are weighted.
¤CI–Confidence Interval (is a range of values within which there is a 95% chance that the true prevalence
estimate lies). *Number of respondents is 50 or less; use caution when interpreting rate.




                                                                                                             76
Asthma in Virginia, 2006

Table 14. Asthma Management and Control Among Adults with Current Asthma, Virginia, 2003-
                                  2004 (combined)
                              Asthma Symptom,         Asthma Medication Use,
                                 Past 30 Days                Past 30 days

                                         Percent 95%CI¤                    Percent 95%CI¤
        Overall Virginia                 68.6 (64.1-72.7)                  69.8 (65.3-73.8)

        Age (years)
         18-24                           66.8 (50.3-80.0)                   63.7 (47.7-77.2)
         25-34                           69.8 (57.8-79.5)                   62.3 (50.9-72.6)
         35-44                           66.2 (55.9-75.1)                   60.3 (50.0-69.8)
         45-54                           68.6 (59.4-76.6)                   67.2 (58.0-75.2)
         55-64                           76.8 (66.4-84.7)                   84.8 (77.0-90.3)
         65+                             65.9 (55.6-74.9)                   84.4 (76.3-90.0)

        Sex
         Male                            70.7 (63.0-77.4)                   69.0 (61.2-75.9)
         Female                          67.5 (62.0-72.5)                   70.1 (64.7-75.0)

        Race/Ethnicity
         White                           68.4 (62.8-73.5)                  69.1 (63.5-74.1)
         Black                           71.3 (61.6-79.4)                  73.2 (63.6-81.0)
         Other                           84.5 (58.4-95.5)*                 75.0 (51.7-89.4)*
         Multiracial                     66.4 (48.3-80.7)*                 70.7 (53.5-83.5)
         Hispanic                        57.6 (34.2-78.0)*                 66.3 (41.8-84.3)*

        Income
          Less than $15,000              83.9 (74.4-90.3)                   84.2 (74.4-90.8)
          $15,000-$24,999                76.4 (67.6-84.4)                   73.9 (65.2-81.0)
          $25,000-$49,999                68.4 (60.4-75.5)                   72.7 (64.9-79.3)
          $50,000-$74,999                63.4 (50.7-74.4)                   55.7 (43.5-67.2)
          $75,000or more                 59.9 (48.4-70.4)                   63.9 (52.1-74.1)

        Education
         Less than HS                    74.1 (64.6-81.8)                   77.7 (69.4-84.3)
         HS graduate                     75.5 (67.5-82.0)                   74.0 (66.0-80.6)
         Some College                    65.8 (56.4-74.1)                   65.7 (56.5-73.9)
         College graduate                62.1 (53.4-70.1)                   65.2 (56.3-73.1)
      Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004. Percentages are weighted.
      ¤CI–Confidence Interval (is a range of values within which there is a 95% chance that the true
      prevalence estimate lies). *Number of respondents is 50 or less; use caution when interpreting rate.




                                                                                                             77
 Asthma in Virginia, 2006

Table 15. Asthma Management and Control Among Adults with Current Asthma, Virginia, 2003-
                                  2004 (combined)
                      Health Care Visits,      ED Visits,          Routine Checkup,
                       Past 12 Months        Past 12 Months          Past 12 Months
                                Percent 95%CI¤               Percent 95%CI¤               Percent 95%CI¤
  Overall Virginia              29.0 (25.1-33.3)             20.9 (17.4-24.8)             56.0 (51.4-60.6)

  Age (years)
   18-24                         24.3 (13.4-39.9)            25.5 (14.1-41.5)             38.5 (24.3-54.8)
   25-34                         23.3 (15.7-33.1)            26.0 (17.8-36.3)             51.4 (40.4-62.2)
   35-44                         38.8 (28.9-49.7)            22.9 (15.0-33.2)             54.2 (43.0-65.0)
   45-54                         33.6 (25.7-42.6)            21.5 (15.3-29.2)             60.5 (51.4-69.0)
   55-64                         26.3 (19.0-35.1)            14.9 (10.0-21.6)             59.6 (48.9-69.6)
   65+                           20.9 (14.7-28.7)             14.3 (8.6-22.8)             67.7 (58.1-76.0)

  Sex
   Male                          20.1 (14.8-26.6)             11.5 (7.7-16.9)             47.8 (40.1-55.7)
   Female                        33.4 (28.2-38.9)             25.4 (20.8-30.6)            60.0 (54.2-65.5)

  Race/Ethnicity
   White                         27.3 (22.8-32.6)            17.3 (13.6-21.8)             56.0 (50.5-61.3)
   Black                         31.4 (22.8-41.5)            29.1 (20.7-39.2)             57.5 (47.4-67.0)
   Other                         11.9 (3.0-36.8)*            24.6 (7.3-57.3)*             35.5 (14.5-64.1)*
   Multiracial                   32.4 (16.6-53.6)            22.2 (10.4-41.2)             46.6 (25.4-69.2)
   Hispanic                      54.1 (31.9-74.9)*           46.2 (25.1-68.9)*            78.5 (59.7-90.0)*

  Income
    Less than $15,000            29.5 (21.3-39.3)            26.6 (18.5-36.5)             59.7 (48.5-70.0)
    $15,000-$24,999              35.7 (26.5-45.9)            29.5 (20.6-40.4)             56.6 (46.6-66.1)
    $25,000-$49,999              31.0 (23.8-39.1)            23.9 (17.3-32.0)             61.5 (53.3-69.1)
    $50,000-$74,999              29.6 (20.1-41.3)             12.5 (7.0-21.1)             45.7 (34.4-57.5)
    $75,000or more               20.8 (13.0-31.7)             15.1 (8.1-26.3)             53.6 (41.6-65.2)

  Education
   Less than HS                  33.3 (25.1-42.7)            33.3 (25.2-42.5)             62.9 (53.2-71.7)
   HS graduate                   28.9 (21.6-37.5)            19.9 (13.6-28.1)             52.9 (43.3-62.4)
   Some College                  28.9 (21.5-37.5)            21.5 (14.8-30.2)             56.3 (47.3-64.9)
   College graduate              27.1 (20.0-35.5)             14.5 (9.5-21.5)             55.1 (46.7-63.2)
Source: Virginia Behavioral Risk Factor Surveillance System, 2003-2004. Percentages are weighted.
¤CI- Confidence Interval (is a range of values within which there is a 95% chance that the true prevalence
estimate lies). *Number of respondents is 50 or less; use caution when interpreting rate.




                                                                                                              78
Asthma in Virginia, 2006

   Table 16. Asthma Hospital Discharge Rates*(per 10,000) by Age, Virginia, 1999-2004
                           1999     2000   2001     2002    2003     2004
              Age (years)
               0-4          49.9    40.4    47.8    38.8     42.1    36.6
               5-14         20.2    16.3    15.5    12.5     14.5    13.5
               15-34         7.9     6.9     6.4     5.5      5.8     4.3
               35-64        13.1    12.2    11.5    10.9     12.4    11.1
               65+          21.9    19.7    18.7    1 9.9    24.3    23.5
               Source: Virginia Health Information Patient Level Data, 1999-2004.
              *Rates are age-specific. Hospital discharge where the primary diagnosis was asthma
              (ICD-9-CM codes 493.0-493.9).

Table 17. Asthma Hospital Discharge Rates*(per 10,000) by Sex and Race/Ethnicity, Virginia,
                                       1999-2004
                                1999    2000      2001     2002     2003     2004
      Sex
       Male                     13.1     10.9     11.2     10.3     11.8     10.2
       Female                   18.1     16.3     15.8     14.6     16.7     15.2

      Race and Ethnicity
       White                          10.0       9.5        9.5         9.1         10.4       9.5
       Black                          27.8       27.1       26.6        24.6        27.7      24.1
       Other                          9.0        7.6        7.0         6.1         6.7        5.3
       Hispanic                       7.1        4.5        6.3         4.8         6.9        6.5
    Source: Virginia Health Information Patient Level Data, 1999-2004. *Rates are age-adjusted to the
    2000 standard U.S. population. Hospital discharge where the primary diagnosis was asthma
    (ICD-9-CM codes 493.0-493.9).

       Table 18. Asthma Hospitalizations by Month of Admission, Virginia, 2002-2004
                                           2002      2003     2004
                     Months

                          January                  895         797         842
                          February                1003         765         902
                          March                    857         830         886
                          April                    688         860         773
                          May                      751         984         826
                          June                     476         846         596
                          July                     472         537         484
                          August                   488         531         579
                          September                927        1018         845
                          October                  945        1073         945
                          November                 895         998         881
                          December                 629        1168         727
                       Source: Virginia Health Information Patient Level Data, 2002-2004.
                       Asthma Hospitalizations where the primary diagnosis was asthma
                       (ICD-9-CM codes 493.0-493.9).



                                                                                                        79
Asthma in Virginia, 2006

Table 19. Asthma Hospital Discharge Rates*(per 10,000) by Health District, Virginia, 2002-2004
                                            2002         2003           2004
              Health District

               Alexandria                         14.4           11.5            12.1
               Alleghany                           7.3           12.8            10.9
               Arlington                           6.1            7.1             6.1
               Central Shenandoah                 11.3           10.9            11.9
               Central Virginia                   18.2           21.5            18.1
               Chesapeake                         11.7           13.1             9.9
               Chesterfield                       14.2           18.1            15.7
               Crater                             26.5           28.1            27.4
               Cumberland Plateau                 23.0           26.9            29.2
               Eastern Shore                      15.4           11.8            10.8
               Fairfax                             7.5            8.2             7.0
               Hampton                             9.1           11.5             8.6
               Hanover                            13.0           15.0            12.8
               Henrico                            16.2           18.4            15.3
               Lenowisco                          18.2           19.8            18.6
               Lord Fairfax                       14.9           17.2            15.8
               Loudoun                             8.2           10.0             8.5
               Mount Rogers                        9.3           10.6             8.6
               New River                           9.8           12.8            12.1
               Norfolk                            16.0           18.1            17.3
               Peninsula                           9.5           12.0             8.6
               Piedmont                           22.9           21.9            24.4
               Pittsylvania/Danville              19.3           20.0            15.9
               Portsmouth                         17.8           22.5            24.1
               Prince William                     12.4           15.5            11.9
               Rappahannock                       16.1           17.5            16.1
               Rappahannock/Rapidan               11.8           12.6            13.3
               Richmond City                      34.1           40.7            33.4
               Roanoke City                       22.7           22.0            20.2
               Southside                          18.5           24.6            17.2
               Thomas Jefferson                   14.8           13.3            11.6
               Three Rivers                       10.4           12.9            11.9
               Virginia Beach                      6.1            7.0             6.2
               West Piedmont                      21.7           15.5            12.9
               Western Tidewater                   9.6           13.1            14.1
            Source: Virginia Health Information Patient Level Data, 2002-2004.
            *Rates are age-adjusted to the 2000 standard U.S. population.
            Hospital discharge where the primary diagnosis was asthma (ICD-9- CM codes 493.0-493.9).




                                                                                                       80
 Asthma in Virginia, 2006

 Table 20. Asthma Hospitalizations, Average Length of Stay (LOS), Average Charges (dollars)
 per Asthma Hospitalization, and Total Asthma Hospitalization Charges (dollars) by Age, Sex,
                              and Race/Ethnicity, Virginia, 2004
                                                         Average Charge           Total
                                       Average LOS
                  Hospitalizations                          (dollars) per   Hospitalization
                                           (days)
                                                          Hospitalization Charges (dollars)
 Age (years)
  0-4                    1826               2.01                5380            9824837
  5-14                   1359               2.30                7536           10242033
  15-34                   892               2.61                8007            7143129
  35-64                  3387               4.06               11657           39484652
  65+                    1996               5.62               14982           29905043

 Sex
   Male                        3624                  3.61                  8783                 31831873
   Female                      5836                  4.01                  11097                64767821

 Race/Ethnicity
  White                        5232                  3.96                  10720                56091327
  Black                        3594                  3.20                  9715                 34917348
  Other                         176                  3.78                  13412                 2360642
  Hispanic                      269                  2.79                  6931                  1864466
Source: Virginia Health Information Patient Level Data, 2004. Asthma hospitalization where the primary diagnosis
was asthma (ICD-9-CM codes 493.0-493.9).




                                                                                                               81
 Asthma in Virginia, 2006

 Table 21. Average Charges per Asthma Hospitalization by Health District, Virginia, 1999-2004
                               1999     2000        2001       2002         2003       2004
 Average Charges (dollars)

 Health District
  Alexandria                           6,690       8,354        8,432        11,875      8,533        13,176
  Alleghany                            5,280       5,324        5,766        8,528       7,880        10,960
  Arlington                            6,656       6,431        8,313        9,922       8,376        9,744
  Central Shenandoah                   2,811       2,933        4,227        4,424       4,603        5,756
  Central Virginia                     4,519       5,452        4,731        5,581       7,436        7,434
  Chesapeake                           5,505       5,234        5,491        6,010       7,512        7,145
  Chesterfield                         9,187       10,257       10,574       11,422      13,772       17,332
  Crater                               6,707       7,193        7,570        7,392       9,990        12,817
  Cumberland Plateau                   6,815       6,858        8,172        8,099       10,138       10,371
  Eastern Shore                        4,688       5,164        5,520        6,558       9,045        8,096
  Fairfax                              6,297       6,689        6,768        7,996       8,943        10,012
  Hampton                              6,173       5,703        6,317        10,532      8,298        9,054
  Hanover                              8,068       9,315        9,436        9,756       12,909       17,900
  Henrico                              6,498       7,597        8,734        10,579      15,599       17,091
  Lenowisco                            4,470       5,183        5,640        6,005       7,339        8,220
  Lord Fairfax                         4,098       4,465        4,588        5,511       4,942        6,193
  Loudoun                              5,752       6,004        5,342        6,709       7,759        8,637
  Mount Rogers                         5,245       5,510        5,365        5,976       7,940        9,542
  New Rivers                           5,962       6,473        6,531        7,918       10,017       11,431
  Norfolk City                         4,641       4,580        5,552        6,428       7,669        8,438
  Peninsula                            5,410       5,245        5,538        6,883       6,825        9,629
  Piedmont                             5,266       5,462        5,930        6,629       6,924        8,658
  Pittsylvania/Danville                4,793       4,684        5,185        5,857       6,211        6,318
  Portsmouth                           4,205       4,318        4,987        4,882       6,353        9,289
  Prince William                       5,232       6,478        6,649        6,844       8,602        7,989
  Rappahannock                         4,893       5,145        5,804        6,884       6,523        7,633
  Rappahannock/Rapidan                 4,911       5,370        5,036        6,241       7,925        8,637
  Richmond City                        7,722       8,239        8,595        8,897       12,872       13,774
  Roanoke City                         6,757       4,108        4,569        6,421       8,791        13,241
  Southside                            5,323       5,793        5,780        6,308       8,000        1,668
  Thomas Jefferson                     3,625       4,123        4,637        4,820       6,463        6,682
  Three Rivers                         5,961       4,845        6,375        8,081       9,248        11,316
  Virginia Beach                       4,789       5,029        5,563        9,197       7,108        9,335
  West Piedmont                        4,893       4,684        5,606        6,238       7,338        7,072
  Western Tidewater                    5,543       5,386        6,208        6,261       8,030        8,400
Source: Virginia Health Information Patient Level Data, 1999-2004. Asthma hospitalization where the primary
diagnosis was asthma (ICD-9-CM codes 493.0-493.9).




                                                                                                              82
Asthma in Virginia, 2006

Table 22. Average Length of Stay (LOS) for Asthma Hospitalization by Health District, Virginia,
                                        1999-2004
                                   1999     2000    2001      2002     2003      2004
     Average LOS (days)

      Health District
       Alexandria                         3.91       4.28       3.99       4.41      3.59       4.27
       Alleghany                          3.48       3.64       3.59       4.59      3.90       4.99
       Arlington                          3.79       3.45       3.89       3.91      3.61       3.83
       Central Shenandoah                 2.69       2.92       2.85       2.85      2.71       3.05
       Central Virginia                   3.40       3.35       2.91       3.01      3.29       3.25
       Chesapeake                         4.28       4.17       3.61       3.65      3.75       3.36
       Chesterfield                       3.48       3.75       3.57       3.60      3.94       4.06
       Crater                             3.47       3.64       3.36       3.04      3.54       3.65
       Cumberland Plateau                 3.20       3.05       3.46       3.37      3.80       3.86
       Eastern Shore                      4.85       4.22       3.62       4.17      4.81       4.54
       Fairfax                            3.52       3.50       3.18       3.38      3.73       3.81
       Hampton                            3.65       3.24       3.09       4.03      3.30       3.30
       Hanover                            3.87       4.21       4.13       3.43      4.12       4.72
       Henrico                            3.34       3.57       3.56       3.68      4.56       4.94
       Lenowisco                          2.70       3.07       3.23       3.20      3.31       2.98
       Lord Fairfax                       3.41       3.37       3.07       3.21      2.96       3.21
       Loudoun                            3.34       3.35       2.85       3.18      3.39       3.43
       Mount Rogers                       4.12       4.01       3.74       3.76      4.33       4.35
       New Rivers                         3.63       3.68       3.36       3.74      3.85       3.86
       Norfolk City                       2.77       2.36       2.73       2.82      3.11       3.07
       Peninsula                          2.95       2.96       2.94       2.89      2.70       3.30
       Piedmont                           3.06       3.10       3.24       3.10      3.13       2.97
       Pittsylvania/Danville              3.05       2.89       2.92       3.08      2.93       2.71
       Portsmouth                         2.75       2.48       2.44       2.82      3.13       3.07
       Prince William                     2.96       3.16       3.13       3.01      3.46       3.21
       Rappahannock                       3.30       3.28       3.15       3.23      3.05       3.01
       Rappahannock/Rapidan               2.94       3.14       2.97       2.93      3.19       3.14
       Richmond City                      3.53       3.40       3.17       3.15      3.83       3.72
       Roanoke City                       3.49       2.84       2.83       3.14      3.56       5.22
       Southside                          3.77       3.72       3.75       3.63      3.56       3.51
       Thomas Jefferson                   2.67       2.79       3.00       2.81      2.90       2.65
       Three Rivers                       3.92       2.87       3.66       3.85      3.75       3.89
       Virginia Beach                     3.03       3.05       3.14       4.05      3.00       3.43
       West Piedmont                      3.41       3.39       3.45       3.45      3.81       3.33
       Western Tidewater                  3.20       3.19       3.16       2.90      3.50       3.49
    Source: Virginia Health Information Patient Level Data, 1999-2004. Asthma hospitalization where the
    primary diagnosis was asthma (ICD-9-CM codes 493.0-493.9).



                                                                                                          83
Asthma in Virginia, 2006

             Table 23. Asthma Mortality Rates*(per 1,000,000) Virginia, 1999-2004
                                1999 2000 2001 2002 2003 2004
                Number          133      127     105     106      118      91

                 Rate                20.1      18.6     15.2      14.9     16.5      12.5
                Source: VDH, Division of Health Statistics, 1999-2004. *Rates are age-adjusted
                to the 2000 U.S. standard population. Asthma death where the underlying cause
                of death was asthma (ICD-10 codes J45-J46).

Table 24. Asthma Mortality Rates*(per 1,000,000) by Age, Sex, and Race, Virginia, 1999-2004
                                         (combined)
                                            Number         Rate
                        Age
                          0-4                   4            +
                          5-14                 19            +
                          15-34                58           4.7
                          35-64               293          16.8
                          65+                 306          62.8

                            Sex
                             Male                     236              12.0
                             Female                   444              19.5

                            Race
                             White                    388              11.8
                             Black                    276              35.5
                          Source: VDH, Division of Health Statistics, 1999-2004.
                          *Rates are age-adjusted to the 2000 U.S. standard population for sex and race,
                          In addition, rates are age-specific for age group. Asthma death where the underlying
                          cause of death was asthma (ICD-10 codes J45-J46).
                          +Rates are not shown if less than 20 asthma deaths were reported.

  Table 25. Asthma Mortality Rates* (per 1,000,000) by Sex and Race Virginia, 1999-2004
                                        (combined)
                  0-4             5-14           15-34         35-64           35-65
             Number Rate Number Rate Number Rate Number Rate Number Rate
  Sex
   Male         3      +       15      +       28     4.5    114   13.3      76     37.8
   Female       1      +       4       +       30     5.0    179   20.1     230     80.2

  Race
   White           3        +        5         +       19        +       114      13.3      223       55.8
   Black           1        +        14        +       39       14.4     148      46.2       74       97.3
 Source: VDH, Division of Health Statistics, 1999-2004. *Rates are age-specific. Asthma death where
 the underlying cause of death was asthma (ICD-10 codes J45-J46). +Rates are not shown if less than
 20 asthma deaths were reported.


                                                                                                             84
Asthma in Virginia, 2006

       Table 26. Asthma Deaths by Health Districts, Virginia, 1999-2004 (combined)
                                                    Asthma Deaths
                      Health District

                        Alexandria                             15
                        Alleghany                              14
                        Arlington                              14
                        Central Shenandoah                     19
                        Central Virginia                       21
                        Chesapeake                             15
                        Chesterfield                           17
                        Crater                                 23
                        Cumberland Plateau                     13
                        Eastern Shore                           9
                        Fairfax                                49
                        Hampton                                13
                        Hanover                                12
                        Henrico                                34
                        Lenowisco                               4
                        Lord Fairfax                           16
                        Loudoun                                 8
                        Mount Rogers                           25
                        New River                              16
                        Norfolk City                           36
                        Peninsula                              17
                        Piedmont                               25
                        Pittsylvania/Danville                  13
                        Portsmouth                             25
                        Prince William                         17
                        Rappahannock                           17
                        Rappahannock/Rapidan                   12
                        Richmond City                          56
                        Roanoke City                           10
                        Southside                               9
                        Thomas Jefferson                       15
                        Three Rivers                           30
                        Virginia Beach                         24
                        West Piedmont                          13
                        Western Tidewater                      24
                     Source: VDH, Division of Health Statistics, 1999-2004.
                     Asthma death where the underlying cause of death was asthma
                     (ICD-10 codes J45-J46).




                                                                                     85
 Asthma in Virginia, 2006

Appendix C. Sources of Data
Behavioral Risk Factor Surveillance System (BRFSS)

The previously defined BRFSS is an ongoing, state-based, random-digit-dialed telephone survey
of the non-institutionalized U.S. population aged 18 years and older sponsored by the Centers
for Disease Control and Prevention. BRFSS is the largest continuing telephone survey in the
world and is conducted annually in all 50 states, the District of Columbia, Guam, the U.S. Virgin
Islands, and the Commonwealth of Puerto Rico. BRFSS data are used to track and monitor the
prevalence of chronic diseases and high-risk health behaviors. It also evaluates progress on
decreasing high-risk behaviors, increasing awareness of chronic disease, and increasing use of
preventive health services.

Virginia has participated in the BRFSS since 1989. A set of core questions on adult asthma is
asked annually. Supplementary questions on asthma are included in the optional section: of the
adult asthma history module and the childhood asthma module. Prevalence estimates of lifetime
and current asthma were established from the responses to these questions for each survey
year and enable us to see trends over time. The answer to these survey questions stands for
only self-reported diagnosed cases of asthma. BRFSS data are directly weighted for the
probability of selection.

Major advantages of the BRFSS survey are: 1) results are comparable from state to state, state
to nationwide, and year to year; 2) allows for surveillance of other risk factors at the same time;
3) flexibility of topic choice from year to year; and 4) BRFSS is the only statewide, random
sample health survey. There are also some limitations that includes: 1) smaller subgroups or
populations (e.g., county), frequently comprise of inadequate observations for extensive or
reliable analysis; 2) information is self-reported; 3) BRFSS data are collected through the
random-digit-dial (RDD) telephone survey and therefore excludes any resident without phone
service. Disparities in health may go with disparities in phone availability, thereby biasing the
sample and the estimates; 4) institutionalized adults (e.g., prisoners, people in adult/nursing
homes) are not surveyed; 5) increasingly, refusal and non-response have become a problem.
The increased use of cell phones, and caller ID makes random sampling difficult; and 6) tracks
only diagnosed asthma cases. Data from Virginia BRFSS, 2002-2004 is included in this report.
U.S. and Virginia BRFSS data are available at:
http://www.cdc.gov/brfss/.




                                                                                                 86
 Asthma in Virginia, 2006

Inpatient Hospitalizations

For this report, all Virginia hospitalizations due to asthma originated with patient level hospital
discharge data compiled by VHI for the years 1999-2004 and submitted to the Virginia
Department of Health under contract. Virginia is the thirty-eighth state to pass legislation
mandating the collection of patient level data. The VHI database contains approximately
800,000 discharges per year for all licensed Virginia hospitals. Discharges for military hospitals
and Veterans’ hospitals are excluded in the VHI database. The findings in this report include
discharges for Virginia residents only. Hospital discharge data are coded under the ninth
revision of the International Classification of Diseases (ICD-9-CM). Any asthma discharge,
defined with a primary diagnosis code of 493.0 through 493.9, is included in this report.

Major strengths: 1) this dataset is based on the entire population, and not a sample of hospital
discharges; 2) it has numerous fields of ICD-9 diagnosis and procedure codes, charges, type
and source of admissions, payment source, and patient demographics. Limitations: 1) reporting
is not complete, extent of missing data not known; 2) rates may be affected by changing
patterns of diagnosis based on reimbursement mechanisms; 3) completeness of details like
patient race is dependent upon reporting hospitals. The dataset still contains close to 5 percent
of discharges for patients of missing of unknown race for this reason; 4) any hospitalizations of
Virginians outside of Virginia are not included in the dataset. Virginians who receive care in DC,
MD, WV, KY, TN, or NC are not included in the VHI dataset. Additional information regarding
Virginia hospital discharge data is available at: http://www.vhi.org/

Mortality Data

Mortality data in this report were obtained from vital statistics data collected and disseminated by
the VDH, Division of Health Statistics. Virginia law mandates collection and publication of all
deaths and the use of standardized forms and definitions for categorizing the underlying cause
of deaths. The cause of death reported in the death certificate is the underlying cause.

Until 1998, asthma death data were coded under the Ninth Revision of the International
Classification of Diseases with ICD-9-CM of 493.0-493.9 as an underlying cause of death. ICD
Revision 10 was introduced in 1999 and therefore, ICD-10 codes of J45 to J46 were used to
categorize deaths with asthma as the underlying cause that occurred from 1999-2004 and
included in this report. Mortality data are used to establish mortality rates and compare
mortality rates. Strengths: 1) complete, since data come from death certificates, which are
required by law; 2) contains all deaths in Virginia (total population rather than just a sample),
including all Virginia residents who die outside of Virginia. Limitations: no information about risk
factors as contributors to death. Additional information on death data in Virginia is available at:
http://www.vdh.virginia.gov/HealthStats/index.asp




                                                                                                  87
 Asthma in Virginia, 2006

School Health Profile

VCHETRC has been contracted by the Department of Education since 2000 to conduct the
SHEP Survey in Virginia. These surveys developed by CDC, present information about health
education in Virginia Public Schools from grades six to twelve and conducted every other year
since 1996. The SHEP evaluates school health policies, programs, and school health curricula
and monitors changes that occur over time in the specific health area. It also provides
information for modifying and or developing health education programs and policies across the
state. All Virginia public schools with at least one of the grades 6 through 12 (except schools in
which the 6th grade was the final grade) were included in this survey.

The principal and the lead health education teacher in every school were asked to complete the
questionnaire. In 2004, SHEP included a question on the principal’s survey regarding the
implementation of school-based asthma management activities. The survey results from 2002-
2004 are included in this report in Table 8. More information available at:
http://www.longwood.edu/vchetrc/surveys.htm

Healthy People 2010

Healthy People 2010 are a set of nationwide health-related goals to achieve over the next
decade, which can help to develop programs for states, communities, and professional
organizations to improve health. Healthy People 2010 are based on initiatives pursued over the
past two decades that include the 1979 Surgeon General's Report, Healthy People, and Healthy
People 2000: National Health Promotion and Disease Prevention Objectives.

It has been designed for two overarching goals: 1) increase quality and years of healthy life to
help people of all ages increase life expectancy and improve their quality of life, and 2) eliminate
health disparities among different segments of the population. There are eight asthma-related
Healthy People 2010 objectives (see appendix D). Additional information on Healthy People
2010 is available at: http://www.healthypeople.gov/




                                                                                                 88
 Asthma in Virginia, 2006

Appendix D. Healthy People 2010 Objectives for Asthma
Healthy People 2010

24-1. Reduce asthma deaths
        In children under age 5 years, from 2.1 to 1.0 per million
        In children aged 5 to 14 years, from 3.3 to 1.0 per million
        In adolescent and adults aged 15 to 34 years, from 5.0 to 2.0 per million
        In adults aged 35 to 64 years, from 17.8 to 9.0 per million
        In adults 65 years and older, from 86.3 to 60.0 per million

24-2. Reduce hospitalizations for asthma
        In children age under 5 years, from 45.6 to 25 per 10,000
        In children and adults aged 5 to 64 years, from 12.5 to 7.7 per 10,000
        In adults aged 65 years and older, from 17.7 to 11 per 10,000

24-3. Reduce hospital emergency department visits for asthma
        In children age under 5 years, from 150.0 to 80 per 10,000
        In children and adults aged 5 to 64 years, from 71.1 to 50 per 10,000
        In adults aged 65 years and older, from 29.5 to 15 per 10,000

24-4. Reduce activity limitations among persons with asthma from 20% (1994-1996 baseline)
        to 10% by 2010

24-5. Reduce the number of school or work missed by persons with asthma due to asthma
        (Developmental)

24-6. Increase the proportion of persons with asthma who receive formal patient
         education, including information about community and self-help resources, as an
         essential part of the management of their condition from 8.4%(1998 baseline) to
         30% by 2010

24-7. Increase the proportion of persons with asthma who receive appropriate asthma care
         according to the NAEPP Guidelines (Developmental)

24-8. Establish in at least 25 states a surveillance system for tracking asthma
         deaths, illness, disability, impact of occupational and environmental factors
         on asthma, access to medical care, and asthma management (Developmental)




                                                                                            89
 Asthma in Virginia, 2006

Appendix E. Virginia Behavioral Risk Factor Surveillance System, Asthma
Questions

Asthma Core Questions (adult)
BRFSS: 2002-2004
    1. Have you ever been told by a doctor, nurse, or other health professional
       that you had asthma?
            Yes
            No
            Don’t know/Not sure
            Refused
     2. Do you still have asthma?
            Yes
            No
            Don’t know/Not sure
            Refused

Asthma History Module (adult): These questions were asked only in adults with current asthma
BRFSS: 2003-2004
    1. How old were you when you were first told by a doctor, nurse, or other health
       professional that you had asthma?

           Age in years 11 or older [96 = 96 and older]
           9 7 Age 10 or younger
           9 8 Don’t know / Not sure
           9 9 Refused

     2. During the past 12 months, have you had an episode of asthma or an asthma attack?

           1 Yes
           2 No
           7 Don’t know / Not sure
           9 Refused

     3. During the past 12 months, how many times did you visit an Emergency Department or
        urgent care center because of your asthma?

           Number of visits [87 = 87 or more]
           8 8 None
           9 8 Don’t know / Not sure
           9 9 Refused




                                                                                            90
Asthma in Virginia, 2006

   4. During the past 12 months, how many times did you see a doctor, nurse, or other
      health professional for urgent treatment of worsening asthma symptoms?

         Number of visits [87 = 87 or more]
         8 8 None
         9 8 Don’t know / Not sure
         9 9 Refused

   5. During the past 12 months, how many times did you see a doctor, nurse or
      other health professional for a routine checkup for your asthma?

         Number of visits [87 = 87 or more]
         8 8 None
         9 8 Don’t know / Not sure
         9 9 Refused

   6. During the past 12 months, how many days were you unable to work or carry out
      your usual activities because of your asthma?

         Number of days
         8 8 8 None
         7 7 7 Don’t know / Not sure
         9 9 9 Refused

   7. During the past 30 days, how often did you have any symptoms of asthma?

         8 Not at any time
         1 Less than once a week
         2 Once or twice a week
         3 More than 2 times a week, but not every day
         4 Every day, but not all the time
         Or
         5 Every day, all the time
         Do not read:
         7 Don’t know / Not sure
         9 Refused




                                                                                        91
Asthma in Virginia, 2006

   8. During the past 30 days, how many days did symptoms of asthma make it difficult
      for you to stay asleep?

         Would you say:
         8 None
         1 One or two
         2 Three to four
         3 Five
         4 Six to ten
         Or
         5 More than ten
         Do not read:
         7 Don’t know / Not sure
         9 Refused

  9. During the past 30 days how often did you take asthma medication that was prescribed
     or given to you by a doctor? This includes using an inhaler.

         Would you say:
         8 Didn’t take any
         1 Less than once a week
         2 Once or twice a week
         3 More than 2 times a week, but not every day
         4 Once every day
         Or
         5 2 or more times every day
         Do not read:
         7 Don’t know / Not sure
         9 Refused




                                                                                            92

				
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