Low asthma hospitalization rates for children in Northern New England may offer some lessons for managing asthma that can benefit young patients throughout the country.
Bucking the national trend of increased hospitalization for children with asthma, New Hampshire experienced a dramatic drop over a ten-year period, a Dartmouth Medical School (DMS) study found. Rates in Vermont and Maine did not change significantly, while those in New York state rose substantially. Although asthma remains a common cause of hospitalization--even in New Hampshire, "These findings are encouraging news for children and their families," says Dr. David Goodman, associate professor of pediatrics and of community and family medicine, who led the study.
Measuring trends in smaller populations can help pinpoint those groups or communities where further efforts to reduce hospitalization are most needed, he points out. "The experience of one population with asthma does not always apply to others; the health care system where you live, your ethnic or racial background and socioeconomic status can all make a difference in the likelihood of hospitalizations. Those differences ought to drive efforts to improve asthma care."
The study is published in the February issue of Pediatrics (the journal of the American Academy of Pediatrics) by Goodman and colleagues Therese A. Stukel, Ph.D. and Chiang-hua Chang of the Center for the Evaluative Clinical Sciences at DMS.
Asthma remains the most prevalent chronic childhood disease and one of the most frequent causes of school absenteeism. Despite national efforts over the last decade to improve asthma medical care, hospitalizations for children continue to rise, even when hospitalization for other common pediatric illnesses is on the decline. While the reasons for these disparities are poorly understood, according to Goodman, these findings show that regional trends do not parallel national trends.
He and his colleagues reviewed hospitalization data in the Northern New England states and New York state between 1985 and 1994 (the most recently available data), to determine if specific regions reflected these national trends or if there were significant differences by population groups. New Hampshire rates fell by almost half from two hospital discharges to one discharge per thousand children under age 18; those in Vermont and Maine did not change significantly. Discharge rates in New York state, on the other hand, climbed from 3.5 to almost five per thousand children.
The state variations appear related to characteristics of population groups as well as differing patterns of medical care. Children in low-income zip codes, metropolitan areas, as well as Black and Hispanic children had substantially higher hospitalization rates, the investigators found. However, the differences among the Northern New England states cannot be explained simply by population differences.
"Northern New England states have similar populations. New Hampshire's decrease in asthma hospitalization is not because there is less asthma, but because of changes in medical care," Goodman says. "An increasingly competitive health care market in New Hampshire appears to encourage clinicians to use outpatient alternatives to hospitalization."
Pediatric hospitalizations are often discretionary and for asthma, most are preventable, Goodman adds. "Hospitalization is considered a failure of health care because environmental risk factors can be altered and good preventive medication is available." Academic medical centers infrequently hospitalize young asthma patients, and the rates for children residing in the Dartmouth-Hitchcock Medical Center area are, in fact, "quite low," he says. High rates are found in New Hampshire communities with populations of low socioeconomic status and where the supply of hospital beds is high.
The investigators note several factors that could account for New York's rising discharge rates when overall pediatric hospitalization declined in all four states. Asthma prevalence and severity could be increasing in poor and minority populations who see physicians less often, or physicians could be labeling more respiratory illnesses as asthma.