Asthma In New England

My 7-year-old daughter had asthma this week, so her spring vacation was a blur of inhalers, visits to the pediatrician and cancelled plans, including a trip to Washington D.C. to visit her cousin. Needless to say, she was bummed out, and because this was her first bout of asthma, her parents were anxious and a little confused.

So for us, today's story in the Boston Globe on asthma in New England was particularly timely. Reporter Stephen Smith writes about the region's distinction as having the nation's highest asthma rate, and the fact that it's poorly controlled in many patients, causing extra trips to the hospital and missed school and work days.

Why are things so bad here? Smith writes:

It has remained a medical mystery why New England has a higher incidence of asthma than the rest of the country. Some specialists theorize cold weather keeps families inside drafty old houses vulnerable to asthma triggers including dust mites, cockroach droppings, and mold. Others suggest there’s something in the air that’s especially nettlesome for asthmatics.

Researchers used sophisticated statistical models to see if differences in education, income, or other factors — perhaps patients were more knowledgeable and, thus, sought care more aggressively —explained higher rates in New England, but no single cause emerged.

In a separate opinion piece on how to better address the high asthma rates, Raymond Considine and Laurie Stillman, president and public health policy director, respectively, of the Boston non-profit,
Health Resources In Action make the case that prevention should be key:

Chronic diseases represent nearly 75% of our nation’s health care expenditures, yet they are largely preventable. The health care industry, government, and businesses have for too long perpetuated a system of illness care that has rendered our nation’s health system unaffordable, and uncompetitive from the standpoint of productivity and cost. The five “Ps” that comprise our health system---Providers, Payers, Purchasers, Public Health, and Policymakers—all have a role in making health reform successful. They can begin by taking their cues from asthma, which suggests a business case for preventing and better managing chronic diseases generally.

Asthma alone costs our country about $20 billion annually. The American Hospital Association estimates that workers with asthma may miss as many as 125 million workdays each year; asthma in children annually accounts for13 million lost school days. The Asthma Regional Council of New England, in partnership with UMass Lowell and the Region I office of the U.S. Department of Health and Human Services, has been monitoring asthma in New England for nearly a decade, with some important observations:

The overwhelming majority of asthma cases are considered to be poorly controlled, based on national guidelines
Prescriptions that can prevent asthma attacks are often placed in higher tier formularies, rendering insurance co-payments unaffordable
Insurance companies do not uniformly align provider reimbursements with evidence based best practices for prevention-oriented care such as patient education, case management, or services from less expensive practitioners that can support high-risk patients.

Published and on-the-ground studies demonstrate that proactive care for asthma in both the clinic and in the community can have positive returns:


Patient self-management education sessions delivered in the clinic, home or workplace have improved poorly managed asthma. Benefits include better medication adherence, less symptoms and activity limitations, and reduced costs for avoidable hospitalizations. Indeed, when targeting the highest utilizers of urgent care, education sessions can generate a positive return on investment for health care payers and business alike.

Numerous federal agencies conclude that providing home-based care for families with uncontrolled asthma, which include environmental assessments and remediation of triggers, can additionally reduce symptom days, activity limitations, and the number of school days missed. These adjunct services have been shown to be cost-effective compared to standard clinical treatment.

Providers other than physicians—including nurses, mid-level practitioners, respiratory therapists, certified asthma educators, social workers, and community health workers—can effectively provide asthma care, often at a lower cost.

Here’s a formula for how the key players can achieve more cost-effective approaches to chronic care delivery:

Policymakers should require the delivery of, and payment for, evidence-based cost effective care for all chronic diseases, in the clinic and in other venues

Providers need to be held accountable for delivering high-quality care and offered the decision-making technology and financial incentives to meet expectations. A multi-disciplinary team approach should be cultivated to provide an integrated range of services, with referrals to a coordinated system of care in the community.

Payers should adequately reimburse for the range of providers and services appropriate for supporting patient self-management, both in and outside the clinical setting, emphasizing targeted, culturally appropriate care and adjunct services.

Purchasers must hold their insurance carriers accountable for incentivizing prevention, while employers should consider offsetting expensive medication co-payments and offering worksite wellness and safety programs.

Public Health must disseminate the evidence-based interventions which help populations stay healthy in the first place. Tracking and targeting diseases at the local level, putting in place the systems and policies needed to support community health, and monitoring health care quality and equity are all important expanded roles for public health in the newly reformed system.

Health care reform will require a deliberate and thoughtful reallocation of resources and strategies that promote preventive interventions, targeting those at greatest risk. A report by The Trust for America’s Health estimates that an investment of $10 per person per year in proven community-based prevention care could save the country more than $16 billion annually within five years. This is a return of $5.60 for every $1 invested.

How can we afford not to invest in practices that reduce disease incidence, symptoms and costs when we have the tools and knowledge to do so?

This program aired on April 26, 2010. The audio for this program is not available.


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