Controlling the Asthma Epidemic in Alaska

Asthma is one of the most prevalent chronic diseases among Alaska’s adults and children. Yet, its heavy burden on the economy of Alaska in terms of absenteeism, unnecessary emergency room visits, hospitalizations, and deaths is largely preventable. Based on its work over the past two and a half years, the broad-based Alaska Asthma Coalition has determined that this impact can be significantly reduced with a modest annual investment of $500,000 for an Asthma Control Program within the Alaska Division of Public Health.

WHAT IS ASTHMA? - Asthma is a critical public health issue that has reached epidemic proportions due to its steady increase in prevalence. Asthma causes a narrowing of small airways that result in shortness of breath, coughing, wheezing, and chest pain or tightness. Exposure to dust, dust mites, mold, pollen, fur or feathered animals, secondhand smoke, cold weather, flu, exercise, and other respiratory infections can trigger an asthma episode. Asthma affects adults as well as children, and an asthma episode at any age can be fatal.

THE BURDEN OF ASTHMA - More than 72,000 Alaskans report that they have suffered from asthma at some point in their lives, and more than 46,100 report a current diagnosis. Approximately 8 percent of children in Alaska have asthma. Rural Alaska Natives have some of the highest documented rates for respiratory diseases, suggesting the same may be true for asthma. Uncertainty about true asthma rates among rural Alaskans is due to a lack of consistency in the diagnosis and treatment of asthma, despite the existence of well-established national guidelines. Between July 2002 and June 2003 there were over $8.6 million spent by Medicaid for asthma in Alaska.

CONTROLLING ASTHMA IN ALASKA - Asthma is an issue facing virtually every segment of Alaska’s population – families, schools, employers and employees, medical personnel, government agencies, and policy makers. As illustrated by the success in other states, a comprehensive asthma control program can reduce the burden of asthma. Even within Alaska, improved diagnosis and treatment among the Alaska Native population in Anchorage has decreased asthma-related hospitalizations. The same can be true for the rest of the state. Although Alaska has not been funded for an asthma control program, Alaska has progressed significantly over the past couple of years through the efforts of the Alaska Asthma Coalition which is composed of 41 organizational members from around the state. The coalition will soon complete an Alaska State Asthma Plan, which, among other recommendations, calls for the creation of a permanent Asthma Control Program in the Division of Public Health. In addition, the Plan recommends an ongoing asthma surveillance program, upon which all subsequent asthma public health interventions depend. In 2003, the American Lung Association of Alaska and Asthma and Allergy Foundation of America- Alaska Chapter received a Congressional earmark to establish the Alaska Asthma Coalition. This funding expires in September 2006. Maintaining the forward momentum of the Coalition and investing in a State Asthma Control Program could result in a return on investment that can be documented in years not decades.

FUNDING REQUEST – The Alaska Asthma Coalition urges the Alaska Legislature to make a modest annual investment of $500,000 for an Asthma Control Program within the Alaska Division of Public Health. These funds will support (1) the personnel necessary to manage the control program, (2) the development of an appropriate ongoing surveillance system, and (3) the implementation of targeted interventions in several rural regions with poor asthma outcomes. These funds will also leverage the continued and substantial in-kind contributions of the members of the Alaska Asthma Coalition.

PREVALENCE

Asthma affects proportionately more children than adults, and more women than men. According to survey data, 12% of adults in Alaska have been told they had asthma at some time in their life with 7% of adults reporting a current diagnosis. The prevalence of current diagnosis is more than twice as high among adult women (10.9%) than among adult men (5.2%) in Alaska. In addition, approximately 8% of adults reported they had a child in their household who has been diagnosed with asthma.

Rural Alaska Natives have some of the highest documented rates for respiratory diseases, suggesting the same may be true for asthma. Uncertainty about true asthma rates among rural Alaskans is due to a lack of consistency in the diagnosis and treatment of asthma, despite the existence of well-established national guidelines.

While there is a need for further analysis of surveillance data and additional epidemiological investigations, in depth examination of data has indicated disparities in rural vs. urban and Alaska Native vs. non-Native health related to pediatric asthma. These disparities include low use of asthma as a diagnosis and low use of inhaled steroids among Native and rural children. Among the Alaska Native Anchorage population, however, increased diagnosis of asthma has occurred in conjunction with increased inhaled steroid use and a decrease in asthma hospitalizations.

• Prevalence of current asthma among adults by income level; Alaska and United States, 2002
• Prevalence of current asthma among adults by associated conditions; Alaska, 2002.
• The percent of persons with asthma among Medicaid recipients less than 20 years of age, by year of service, race, and residence; Alaska, 1999-2002.

Alaska is one of many states without an asthma control program, yet controlling asthma is an issue facing virtually every segment of Alaska’s population – families, schools, employers and employees, medical personnel, government agencies, and policy makers. As illustrated by the success in other states, a comprehensive asthma control program can reduce the burden

Health economics are receiving more attention as decision makers seek a more comprehensive understanding of the positive long term impact of adopting new health care strategies. The economic costs of asthma are considerable both in terms of direct medical costs (hospitalizations, emergency department visits, pharmaceuticals) and indirect costs (loss of time at school and work affecting academic achievement and work productivity and premature death). In order to reduce costs and improve quality of care, Alaska needs to target ways of controlling rapidly rising health care costs.

Between 2001 and 2004, there were 1,824 hospital discharges with asthma as a primary diagnosis resulting in total charges of approximately $17 million spent in Alaska. That’s an average of $9,200 per discharge. These figures don’t include small rural tribally managed hospitals, therefore we can expect the expenditures to be significantly higher.

Anchorage residents have the benefit of subspecialty care, asthma education programs, and for Alaska Natives, a well-coordinated approach to asthma management implemented by the Alaska Native Medical Center and Southcentral Foundation. However, few interventions are currently directed toward rural populations and no overall asthma control program coordination exists in the state. A coordinated statewide approach to asthma control could achieve benefits similar to those seen for Anchorage Alaska Natives for other, primarily non-Anchorage-based residents.

• The percent of persons with asthma requiring hospitalization among Medicaid recipients less than 20 years of age, by year of service, race, and residence; Alaska, 1999-2002.

In 2003, the American Lung Association of Alaska (ALAA) and Asthma and Allergy Foundation of America- Alaska Chapter (AAFA-AK) received Congressional funding to address asthma in Alaska. ALAA committed to develop an Alaska Asthma Coalition and sponsor Alaska Asthma Summits with the goal of developing an Alaska State Asthma Plan in lieu of a state asthma program due for completion by May, 2006. Current funding expires September, 2006.

ALASKA ASTHMA COALITION

Although Alaska has not been funded for an asthma control program, Alaska has progressed significantly over the past couple of years through the efforts of a strong Coalition. The Alaska Asthma Coalition consists of committed public, private and school health professionals, pharmacists, payers, parents, patients, non-profit health and environmental organizations and the Alaska Native Tribal Health Consortium.

The Alaska Asthma Coalition has worked extensively to:

• Develop an Alaska Asthma Plan that will guide the State in addressing asthma;
• Analyze data sets and establish relationships with third party payers (Medicaid and Premera/Blue Cross Blue Shield) to access the burden of asthma in Alaska;
• Coordinate two successful statewide Alaska Asthma Summits (September 2004, December 2005) to disseminate information, develop partnerships, and work on the Alaska State Asthma Plan.
• Create a network of partners and technical advisors whom are committed to improving asthma outcomes in Alaska.
• Lobby successfully for a law (HB85) allowing students with asthma to carry and self-administer their medications at school;
• Implement a variety of media and education interventions;
• Develop and promote a prototype Student Asthma Action Card available to all schools to improve asthma management in the school;
• Develop and promote a prototype Allergy/Anaphylaxis Plan available to all schools to improve allergy treatment in school;
• Develop a Web-based Interactive Asthma Action Plan available to health care providers to improve conformity with national guidelines.
• Establish partnerships with successful asthma management models in Alaska (Alaska Native Medical Center).

Health Care Costs are an increasing and threatening economic concern.
The costs of chronic disease is a major component of total health care cost.
Asthma is a major component of chronic disease cost.
Efforts to improve asthma care are logical and needed.

Approximately 115,000 Alaskans have no health insurance coverage. Many others have minimal or inadequate coverage. Thousands are turning to hospital emergency rooms as a source of primary health care, often without ability to pay. Adequate health care in remote areas is a significant logistical, financial and educational challenge.

Between July 2002 and June 2003 there were over $8.6 million spent by Medicaid for asthma in Alaska. Medicaid costs to the State of Alaska are rising dramatically, to over $1 billion in 2005. This is placing a strain on the state budget. Most of the morbidity and mortality from asthma can be prevented if the disease is managed according to established national guidelines for the diagnosis and treatment of asthma. By increasing provider compliance with these guidelines, promoting self-management, and ongoing monitoring of the disease, we would bring economic benefits by lowering emergency department visits and hospitalizations as well as improve the
quality of life for Alaskans affected by asthma.

As was described in a recent Commonwealth North document titled Alaska Primary Health Care: Opportunities and Challenges, “Alaskans must identify and improve aspects of health care that are under our control. Many health care issues are national, something Alaskans can not effect. Therefore, it’s even more important to address and solve issues we can do something about.” ASTHMA IS ONE OF THEM!

The Alaska Asthma Coalition urges the Alaska Legislature to make a modest annual investment of $500,000 for an Asthma Control Program within the Alaska Division of Public Health. These funds will support (1) the personnel necessary to manage the control program, (2) the development of an appropriate ongoing surveillance system, and (3) the implementation of targeted interventions in several rural regions with poor asthma outcomes. These funds will also leverage the continued and substantial in-kind contributions of the members of the Alaska Asthma Coalition.
Examples of activities that will be supported with these grant funds include:

• Conduct asthma surveillance to further assess the distribution of asthma prevalence, morbidity, and mortality.
• Conduct descriptive epidemiological investigations that will identify the relationships among risk factors and asthma incidence specific to Alaska residents.
• Establish a clearinghouse (including Web-based) of high quality, culturally appropriate and easily understood asthma education materials.
• Develop and pilot programs to educate public about ways to reduce exposure to asthma triggers in their homes, schools, and workplaces.
• Promote the use of appropriate evidence-based asthma disease diagnosis and management models.
• Enhance cultural competency of current asthma education curriculum to be incorporated into rural health provider training.
• Promote children and adults with asthma to have a written asthma management plan.
• Sustain the Alaska Asthma Coalition.
• Maintaining the forward momentum of the Coalition and investing in a State Asthma Control Program could result in a return on investment that can be documented in years not decades.
• A sustainable, integrated surveillance system will be established in Alaska to develop, implement, and evaluate effective asthma prevention and management interventions. This information will be used the guide interventions and policies to improve outcomes and reduce disparities.
• Improve the understanding and management of asthma for patients, their families, health care providers, and educators which will result in decreased absenteeism from school and work therefore increasing academic achievement and work performance.

The return on this investment will be evaluated by establishing a series of indicators to measure achievement. 1) short-term process objectives (such as the activities bulleted above), 2) interim impact goals (e.g., decreased hospitalization and emergency department utilization resulting in reduced asthma-related health care costs), and 3) desired long-term outcomes (e.g., decreased asthma-related mortality and morbidity and improved quality of life for people with asthma).

• More than 72,000 Alaskans report that they have suffered from asthma at some
  point in their lives and more than 46,100 report a current diagnosis.
• Among persons <20 years of age enrolled in Medicaid, asthma prevalence doubled during 1999-2002.
• Between July 2002 and June 2003 there were over $8.6 million spent by Medicaid for asthma in Alaska.
• Obese adults are almost 50% more likely to report current asthma than other adults.
• Rural Alaska Natives have some of the highest rates ever documented for specific respiratory diseases, suggesting the same may be true for asthma.
• Asthma is the leading cause of school absenteeism resulting in 14 million days missed annually in the U.S.
• There were over 5,670 asthma related school nurse visits in the Anchorage School District between September 2004 and May 2005 for grades K-6.

Coaltion Members

* Alaska Building Science Network
* Alaska Center for Pediatrics
* Alaska Health Education Consortium
* Alaska Native Medical Center (ANMC) Asthma Committee
* Alaska Native Tribal Health Consortium
* Alaska Nurse Practitioner Assoc.
* Alaska Nurses Association
* Alaska Pharmacy Association
* Alaska Primary Care Association
* Alaska Public Health Association
* AK Society for Respiratory Care
* Alaska Thoracic Society
* Allergy & Asthma Network Mothers of Asthmatics (AANMA)
* American Heart Association
* American Lung Association of Alaska
* Anchorage School District
* Asthma & Allergy Foundation of America – Alaska Chapter
* Boehringer Ingelheim Pharmaceuticals
* Bristol Bay Area Health Corp.
* Centers for Disease Control/National Institute for Occupational Safety and Health
* Denali Center Fairbanks Memorial
* Elmendorf Air Force Base Health Promotions
* Fort Richardson Health Promotions
* First Health Services Corporation
* Genentech Pharmaceuticals
* GlaxoSmithKline Pharmaceuticals
* Municipality of Anchorage - Environmental Health
* PREMERA Blue Cross Blue Shield
* Professional Infusion Pharmacy
* Providence Alaska Medical Center
* Solutions to Healthy Breathing
* Southcentral Foundation
* Southeast Alaska Regional Health Consortium
* State of Alaska Department of Health and Human Services Division of Public Health
* State of Alaska CHEMS Health Promotions
* State of Alaska Division of Medicaid
* The Nerland Agency
* United States Department of Veterans Affairs
* University of Alaska Health/Fairbanks
* University of Alaska Anchorage/Circumpolar Health Studies
* Yukon-Kushkokwim Health Corporation