Treating asthma as a serious public health problem
This article first appeared in the St. Louis Beacon, Feb. 20, 2012 - The American Lung Association is trying to mobilize groups nationwide to fight plans by the Obama administration to consolidate some asthma programs and reduce funding for them. St. Louis has one of the nation's highest rates of asthma. The local cost of treating the illness increases when parents of children with asthma turn to costly emergency rooms for treatment.
Under Obama's proposed budget, the Centers for Disease Control and Prevention would fold the National Asthma Control Program into an umbrella organization focusing not only on asthma but on reducing other environmental health hazards, such as air pollution, lead poisoning, second-hand smoke and radon.
The Lung Association's CEO, Charles D. Connor, says the group will appeal to health partners to start a "nationwide campaign" to save the asthma program. The association also noted that that it had persuaded Congress to reject similar changes the administration sought to make last year.
While the CDC said it would continue to fund evidence-based asthma-control programs, but would put less focus on surveillance and more attention on training health professionals and educating the public about managing asthma. The new approach would reduce to 19 the number of asthma grants made nationwide in the next fiscal year, which begins Sept. 1, down from 65 each during the previous two fiscal years. The CDC's environmental health budget of $139.9 million would be reduced by $7.3 million in the coming fiscal year. The agency added that some cuts would be offset by cutting duplicate services.
Impact on the St. Louis region
Among those watching these developments and what they mean to the region is Dr. William Kincaid, head of the St. Louis Regional Asthma Consortium. Kincaid has been a medical practitioner, a public health official, a medical director of a managed care plan and, more recently, a volunteer with many nonprofit health groups. His preference, like the CDC's policy shift, leans toward more training and public education.
"The issue is not more money," he says. "The issue is using the money already in the system more effectively."
The asthma consortium has worked with the Lung Association, the CDC, state health officials and health officials in St. Louis and St. Louis County.
As for the controversy between the Lung Association and CDC, Kincaid says, both sides have merit. On the one hand, he says, the Lung Association's reaction is an example of "special interests rallying the troops to change federal funding priorities." On the other, he says the CDC has done an "excellent job" in asthma treatment and prevention, based in part on work by local groups such as the consortium. The CDC also has funded Missouri's asthma control and prevention program, he says.
What's missing, he says, is a balance between the medical and public-health approaches to the problem, including more initiatives to educate providers and the public about asthma and how to control it. The consortium's efforts have included encouraging doctors to develop patient-specific asthma action plans.
"These plans," he says, "are really standing orders to be used by parents or a school nurse to manage acute attacks."
This approach and early use of medications can prevent the need to "send the child to an ER or to call parents to take time off work to take care of the child (through) an urgent care visit."
St. Louis ranks sixth in the nation in asthma, with Richmond, Va., having the highest rate. The most recent data by the Missouri Department of Health and Senior Services show that 21 black children under age 15 died from asthma between 2000 and 2007. During that same period, the agency reported that eight white children in the same age group died of the illness.
For a three-year period, from 2005 to 2007, the agency reported that asthma-related mortality for blacks in Missouri was 2.5 for every 100,000 people. For whites, it was 0.9 for every 100,000 people. This means the rate for blacks was 2.8 times higher than for whites, according to a DHSS report, Putting Excellent Asthma Care Within Reach (2010-2014).
The data also showed the disease generated many emergency room visits and hospitalizations among young black children across the state. In 2009, for example, Department of Health officials reported 29,600 ER visits and 8,200 hospitalizations relating to asthma. The cost of asthma-related ER visits exceeded $37.5 million in 2009. Overall hospital charges for asthma treatment exceeded $96 million.
Data from 2007 showed that seven of every 1,000 white children between the ages of 1 and 4 visited ERs for asthma, compared to 45.8 of every 1,000 black children. In addition, white children in the 1-4 age group were hospitalized for asthma at a rate of 27.1 for every 10,000, compared to a rate of 83.1 for every 10,000 black children.
Asthma as a public-health problem
Kincaid says a missing ingredient is education. "Many asthmatics do not receive good outpatient medical care," he says. Only 10 percent of those going to an ER for an asthma attack visit a doctor in the next three months. In addition, the condition is often under-treated because patients may not fill prescriptions for controller inhalers because of the cost of the medication. Unlike rescue inhalers, which bring immediate relief, controller inhalers require months to reduce symptoms and control chronic lung inflammation that triggers acute attacks.
Kincaid says public-health officials, locally and around the state, have worked to understand the issues surrounding asthma as a public-health problem.
The changes in funding proposed by the federal government "raise important policy questions," he says, adding that the current system largely treats asthma under a medical model.
With few exceptions, he says the medical models and public-health models function independently, "moving through the community on parallel tracks, not operating as one. This is a huge mistake. Poor policies are leading to higher costs and poor outcomes."
But he sees hope in a new federal initiative called Innovation Challenge grants. The government is setting aside $1 billion for projects that produce creative ways to deliver medical care and save money. Kincaid said the local asthma consortium and four other groups have applied for a grant.
The program seeks to address asthma and other problems through systemic approaches, involving medical care, behavioral health, education, empowerment and epidemiology, Kincaid says.
His hope is that through an innovation grant, public-health officials can form a partnership with hospitals, physicians and Medicaid managed care plans.
"This would unite those groups that have a stake in asthma to develop a statewide program based on best practices from the medical and public health worlds," he says.
The goal would be to "redirect money currently spent at the high-cost end of the asthma problem -- on hospitals and emergency rooms -- to educational and environmental interventions in neighborhoods and among individuals at high risk." He concedes the long odds of winning one of the grants, which the federal government will announce as early as next month and as late as the fall.
"The odds are long that the application will be successful," Kincaid says. "But these kinds of paradigm shifts are needed if we are going to improve patient outcomes and lower costs."