In response to a request for a proposal from the Centers for Disease Control and Prevention (CDC), the Michigan Department of Community Health (MDCH) in conjunction with Michigan State University (MSU) successfully competed to obtain funds to develop a rapid asthma death notification and investigation system for the State of Michigan. This system was limited, at the request of CDC, to investigations of asthma deaths among children and young adults ages 2-34. CDC selected this age group because of the increased likelihood that deaths ascribed to asthma in the ages 2-34 were truly caused by asthma. For individuals younger than the age of two or older than the age of 34 the number of other medical conditions that may present with symptoms similar to asthma increases.
Asthma mortality rates in Michigan are slightly higher than the United State’s rate for all age groups except among adults 65 and older. Overall asthma mortality rates in Michigan did not change significantly between 1990 and 2002 with the exception of people ages 65 and older. Asthma mortality rates in this age group dropped significantly between 1990 and 2002, with the largest reduction in rates occurring between 1998 and 1999. The mortality rate in Michigan for asthma in African-Americans of all ages (48.5 per million) was over four times that of Caucasians (11.5 per million). This racial difference in asthma mortality rates was even greater in the 5-34 year old age group (African-American vs. Caucasian, 17.5 vs. 1.8/1,000,000, ages 5-14 and 24.2 vs. 4.1/1,000,000, ages 15-34).
Next-of-kin of the deceased are interviewed and medical records, medical examiner’s reports, and pharmacy records are reviewed. A two-page summary of the information is written and presented to a review panel consisting of allergists, asthma educators, emergency department physicians, family practitioners, internists, nurses, pediatricians, pharmacists, pulmonologists, respiratory technicians, and social workers. There are separate panels to review the adult and children deaths. The findings from these investigations are shared with health care providers, public health personnel, health educators, and medical administrators.
The primary causal factor identified in the first two years of investigation was the lack of compliance by patients with good asthma management including regular use of inhaled steroids rather than dependence on Beta agonists and elimination of asthma triggers such as cigarette smoke and pets. Some of the deficiencies noted in asthma management were from inadequate prescription on inhaled steroids particularly in emergency departments. The low percentage of asthmatics with asthma management plans (only 9%) would suggest that more can be done by the health care system to encourage patient compliance. Particular recommendations were made for:
- Case managers for high risk patients (patients with an Emergency Department visit and/or a hospitalization for asthma).
- Case managers for asthmatics with psychiatric conditions and education on asthma for psychiatric health care providers.
- Pharmacy notification to doctors for patients who repeatedly fill Beta agonist prescriptions or possibly placing a limitation on the number of refills allowed.
- Provision of more comprehensive asthma care in Emergency Department-Education and inhaled steroids.
- Referral to specialist for patients with a hospitalization and/or Emergency Department visit for asthma.
- Need for health insurance for asthmatics, (more of a problem in adults than children).