Asthma

August2003

The impact of multiple chronic conditionsIntroduction

According to a 2001 survey by the Center for Disease Control and Prevention, there are approximately 31.3 million Americans diagnosed with asthma at some point during their lifetime.1 Among all the age groups, children 5-17 years of age have the highest prevalence rates.2 “Asthma is the leading cause of school absences from a chronic illness. It accounts for an annual loss of more than 10 million school days per year and more hospitalizations than any other childhood disease. Children with asthma spend an estimated 7.3 million days per year restricted to bed.”3

Most People With Asthma have other Chronic Conditions

According to Figure 1, over two thirds of people with asthma have one or more other chronic conditions, and more than half of the asthmatics have two or more in addition to asthma. However, little attention has been paid to the issue of co-morbidities among asthmatic patients. The most common co-morbidities are shown in Table 1.

As seen in Figure 2, more than 80 percent of asthmatics age 0-17 have no co-morbidities. However, the prevalence of co-morbidities increases with age. By the time the population has reached age 65, only 6% of people have asthma only. The number of people

1 Trends in Asthma Morbidity and Mortality American Lung Association, Accessed July 2003, <http://www.lungusa.org/data/asthma/asthma1.pdf> p.52 Ibid3 Asthma Facts and Figures Asthma and Allergy Foundation of America, Accessed July 2003, <http://www.aafa.org/templ/display.cfm?id=2&sub=29>

Source: Large Private Insurer, CY 2001

with 5 or more chronic conditions in addition to

asthma also increases with age. One percent of

Table 1Conditions Percent of Asthma

Patients AffectedHypertension 25.9%Hyperlipidemia, hyperglyceridemia, hypercholesterolemia and other disorders of lipid metabolism 18.4%COPD 16.1%Diabetes 10.4%Coronary atherosclerosis 9.4%

children seventeen or less have five or more other chronic conditions, by the time the population has reached 65, more than one third of the population have more than five other chronic conditions in addition to asthma.

There’s some limited clinical research discussing the impact of co-morbidities on treating asthmatics. As shown in Table 1, slightly more than a quarter of asthma patients have hypertension, and some studies have suspected the possibility of a positive correlation.4 Other studies have shown a positive correlation between asthma and type 1 diabetes.5 The presence of these co-morbidities may complicate treatment; however, information on treating asthma patients with other chronic conditions is limited. Nevertheless, improving the quality of treatment remains an important issue, since research has already shown that co-morbidities, especially cardiac disease and hypertension, result in poor health-related quality of life (HRQoL) in asthma patients.6

Health Care Spending Increases With Number of Chronic Conditions

Figure 3 shows that spending on people with asthma increases with the number of chronic conditions. People with asthma and five or more chronic conditions have approximately eight times more expenditures per enrollee compared to enrollee with only asthma.

4 Salako BL, Ajayi SO. (2000) Bronchial asthma: a risk factor for hypertension? Afr J Med Med Sci. 29(1): 47-505 Stene LC, Nafstad P.(2001) Relation between occurrence of type 1 diabetes and asthma. Lancet. 24;357(9256):607-8.6 HA Wijnhoven et al. (2003) The influence of co-morbidity on health-related quality of life in asthma and COPD patients. Respir Med. 97(5): 468-75

Hospitalization Rates Increase as the Number of Chronic Conditions Increases

Source: Large Private Insurer, CY 2001

Many asthmatics have one or more ambulatory care-sensitive conditions, or ACSCs. ACSCs are defined as conditions for which “diagnoses for which timely and effective outpatient care can help to reduce the risks of hospitalization by either preventing the onset of an illness or condition, controlling an acute episodic illness or condition (such as bacterial pneumonia), or managing a chronic disease or condition (such as asthma and hypertension.)”7

7 Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE, Newman L. Impact of socioeconomic status on hospital use in New York City Health Affairs(Millwood). 1993:12:p.163-166

Table 2Number of Chronic Hospitalizations forConditions in ACSC AdmissionsAddition to Asthma per 1000

0 11.11 18.82 33.03 58.24 93.15+ 258.7

It has been observed that “better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.”8

Hospitalization for conditions (ACSCs) that are preventable can be used to indicate whether the patient is receiving adequate and quality outpatient care.9

Utilization Increases with Number of Chronic Conditions

People with multiple chronic conditions in addition to asthma utilize more healthcare resources. As Figure 4 shows, patients with more chronic conditions visit doctors more often. As shown in Figure 5, patients with five or more chronic conditions in addition to asthma see nearly three times as many doctors as does a patient with asthma alone.

8 Anderson G., Starfield B, and Wolff J. (2002) Prevelence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly Arch Intern. Med. 162(20): 2269-76 9 Millman M. Access to Health Care in America Washington, DC: National Academy Press; 1993

Coordination of Care: The Concept of “Medical Home”

The American Academy of Pediatrics (AAP), defines medical home as a place where medical care is accessible, continuous, comprehensive, family-centered, coordinated10, compassionate and culturally effective11. Lack of a medical home may cause unnecessary hospitalizations; in fact, research has demonstrated that “hospitalization due to acute severe asthma represents a failure in the preventive, long-term as well as home care of asthma.”12 Care in the context of a medical home is also more cost-effective, as the AAP points out: “care provided through emergency departments, walk-in clinics, and other urgent-care facilities…is more costly and often less effective.”13

10 American Academy of Pediatrics, Committee on Children With Disabilities. Care coordination: integrating health and related systems of care for children with special health care needs. Pediatrics. 1999; 104:978-98111 American Academy of Pediatrics, Committee on Pediatric Workforce. Culturally effective pediatric care: education and training issues. Pediatrics. 1999;103:167-17012 Singh M. (2001) Management of acute asthma. Indian J Pediatr. 68 Suppl 4: S23-30 13 American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory

Conclusion:Treatment has become increasingly

difficult when asthma patients have other chronic conditions. Research suggests that patients have better outcomes at lower cost when care is coordinated14. Care coordination becomes essential to improvements in care for patients with lung cancer.

About Partnership for SolutionsPartnership for solutions, led by Johns

Hopkins University and the Robert Wood Johnson Foundation, is an initiative to improve the care and quality of life for the estimated 125 million Americans with chronic health conditions. The Partnership is engaged in three major activities conducting original research and identifying existing research that clarifies the nature of the problem; communicating these research finding to policymakers, business leaders, health professionals, advocates, and others; and working with public and private programs to identify promising solutions to the problems faced by people with chronic conditions.

Committee. The Medical Home. Pediatrics. 2002;110:184-18614 Anderson G, Starfield B, and Wolff J. Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly Arch Intern. Med. Vol. 162, Nov. 2002, p. 2275