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Missouri Asthma Prevention and Control Program Page 1
Missouri Asthma Prevention and Control Program
Surveillance Update
Missouri Department of Health and Senior Services
Division of Community and Public Health
February 2017
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
Services provided on a nondiscriminatory basis.
Missouri Asthma Prevention and Control Program Page 2
Report Information
Title: Missouri Asthma Prevention and Control Program: Surveillance
Update
Description: This report provides an update on program and partnership
activities and the impact on the burden of asthma in terms of acute health
care utilization trends and particularly in selected areas with asthma
champions.
Audience: This report is intended for use by partners and stakeholders, state and local policy makers,
researchers, health care personnel, local public health agencies, voluntary organizations, funders, and
the general public.
Grant Support: This report was supported by a cooperative agreement between the Centers for
Disease Control and Prevention (CDC) and Missouri Department of Health and Senior Services
(DHSS) (#5U59EH000510). Its contents are solely the responsibility of the authors and do not
necessarily represent official views of the CDC.
Acknowledgment:
The authors would like to thank Marjorie Cole for continuous program and school initiatives support
and Supriya Nelluri for providing smoking during pregnancy data.
Suggested Citation: Homan SG, Gaddy P, Yun S, Armbrecht E, Rood T, Francisco B. Missouri
Asthma Prevention and Control Program: Surveillance Update 2017. Jefferson City, MO: Division of
Community and Public Health.
Permission to copy, disseminate, or otherwise use information from this report is granted as long as
appropriate acknowledgment is given.
Missouri Asthma Prevention and Control Program Page 3
Executive Summary Asthma is a major chronic respiratory condition that may lead to disability and adversely affect quality
of life when not well controlled. In 2014, more than one-half million adults (9.7%) and children
(11.2%) were living with the condition in Missouri. Pediatric asthma results in missed learning
opportunities, elevated acute health care utilization, and costs. Established in 2001, the Missouri
Asthma Prevention and Control Program (MAPCP) mission of reducing the impact of asthma in
Missouri has continued. Integrating clinical care and public health has yielded strong partnerships and
innovative interventions for improved asthma outcomes in the pediatric population. The asthma
program has helped create and put in place large scale interventions such as the Teaming Up for
Asthma Control (TUAC), partner initiatives such as Childhood Asthma Linkages in Missouri (CALM),
and countywide comprehensive initiatives (Dunklin and Washington counties) which involved training
school nurses and health care providers and strengthening linkages between school nurses and primary
care doctors. Continued improvement in systems of care and changes in policy will improve quality of
life and decrease direct and indirect economic loss attributed to asthma. Analysis of hospital
discharges, emergency department (ED) visits, and Medicaid claims data demonstrate that positive
changes are occurring statewide.
Emergency Department Visits and Hospitalizations
The age-adjusted asthma hospitalization rate decreased significantly from 12.4 in 2000 to 11.5
in 2014 per 1,000 population, with a steady decline from 2008-2013.
Among children, there have been significant declining trends in asthma hospitalization rates per
10,000 population among children for three of the four age groups: < 1 year from 33.5 in 2002
to 8.5 in 2014; 1 to 4 years from 41.6 in 2004 to 35.8 in 2014; and 10 to 14 years from 14.7 in
2000 to 11.0 in 2014. Among children aged 5 to 9 years, there was a significant increase in
asthma hospitalizations comparing 2004 and 2012 (18.9 vs 24.0 per 10,000 population).
Although African-Americans are disproportionately affected by asthma and have consistently
had higher ED visits and hospitalizations from the disease than whites, there has been a
significant downward trend for asthma hospitalizations among African Americans (all ages
combined) from 41.9 in 2008 to 35.5 per 10,000 population in 2014. There has also been a
23.1% decrease in the racial disparity for asthma hospitalizations between white and African-
American children younger than 15 years of age.
In Dunklin County, the asthma hospitalization rates among children ages 14 and younger fell
from 160.4 in 2002 to 37.0 per 10,000 children in 2014.
In Washington County, the asthma emergency department visit rate was reduced by almost
one-half, from 20.3 in 2002 to 10.2 per 1,000 children in 2014, although asthma ED visit rates
for Missouri remained steady.
In areas such as Barton, Cedar and Polk counties with the CALM program and other initiatives,
there was a decline in asthma ED visit rates among children < 15 years of age for the three
combined counties from 7.7 in 2003 to 4.8 per 1,000 children in 2008, but this was not
statistically significant.
Missouri Asthma Prevention and Control Program Page 4
Three Group Comparisons: MO HealthNet, CHIP, and Non-MO HealthNet
The Missouri Department of Social Services (DSS) provides health care for uninsured children through
the Children’s Health Insurance Program (CHIP). In 2007, Missouri's CHIP began operating as a
combined Medicaid/CHIP program, entitled MO HealthNet for Kids. The Missouri Children’s Health
Insurance Program (CHIP) and Show Me Healthy Babies Annual Report 2016 revealed:
From 2000 to 2014, there was a significant decrease in asthma preventable hospitalizations
among MO HealthNet (Medicaid children) population (-34.8%, p < 0.001) and for the non-MO
HealthNet group (-18.2%). Preventable asthma hospitalizations for the CHIP population
decreased by 39.0%.
In 2014, the CHIP preventable hospitalization rate of 1.7 per 1,000 children was 24% lower
than the national benchmark rate of 2.25 asthma preventable hospitalizations per 1,000
children. The MO HealthNet population remained 33% higher than the national benchmark.
Smoking among Pregnant Women
For children < age 1 from 2000 to 2014, there have been significant declining trends in asthma
ED visits and hospitalizations. Likely contributing to these declines is the significant decline in
the prevalence of smoking among pregnant women in Missouri from 24.8% in 1990 to 16.7%
in 2014. Nevertheless, the prevalence of smoking among pregnant women in Missouri remains
almost twice that of the U.S. in 2014 (16.4% vs 8.4%).
Health Outcomes
The MAPCP has launched evaluations of two large scale asthma control strategies: The Early
Childhood Asthma Initiative (ECAI) and Teaming Up for Asthma Control (TUAC). The ECAI
provided asthma control training, tools, and equipment to staff in local public health agencies (LPHAs)
statewide. The staff provided information to childcare centers on indoor air quality and asthma triggers
and education to families on in-home air quality and asthma management in pre-school children.
”Teaming Up for Asthma Control” is a work force development intervention to improve asthma
control among children by increasing school nurse competency through online education and expert
mentoring and delivering guideline-based education. These initiatives have increased provider
knowledge and health outcomes among children including:
Improved lung function, inhalation technique, psychosocial indicators, increased use of control
medication (i.e., inhaled corticosteroids), and reduced impairment and tobacco smoke
exposure.
For children enrolled in TUAC and MO HealthNet, there was a decline in the post-intervention
12-month total health care utilization cost.
Mortality
There has been a significant decline in asthma mortality rates among whites from 1.1 in 2000 to
0.5 per 100,000 population in 2011 and also a decline, but not significant, among African
Americans from 5.1 in 2000 to 4.4 per 100,000 in 2014; however, in 2014 significantly more
African-Americans died of asthma than whites, 4.4 versus 0.9 per 100,000 population.
Conclusion Reducing the morbidity associated with asthma remains a significant public health challenge in Missouri and in
the nation. The progress toward reducing the burden of asthma is demonstrated in the overall decline in asthma
hospitalizations, disparities, and deaths in Missouri, but more needs to be done with substantial disparities
persisting.
Missouri Asthma Prevention and Control Program Page 5
Table of Contents
Executive Summary………………………………………………………………….. 3
Introduction…………………………………………………………………………… 7
Asthma and School Health…………………………………………………………… 7
Key Initiatives………………………………………………………………………… 8
Prevalence and Morbidity Trends…………………………………………………... 9
Prevalence
Emergency Department Visits and Hospitalizations
State and Selected County Comparisons
Three Group Comparisons: MO HealthNet, CHIP, and Non-MO HealthNet
Smoking among Pregnant Women
Health Outcomes……………………………………………………………………… 21
Mortality Trends……………………………………………………………………… 22
Conclusion…………………………………………………………………………….. 22
References…………………………………………………………………………….. 23
Tables
1 Asthma School Health Initiatives
Figures
Prevalence
1 Current Asthma Prevalence among Adults ≥ 18 years of age, Missouri and U.S.
2 Current Asthma Prevalence among Children ≤ 17 years of age, Missouri and U.S.
State Population
3 Asthma Emergency Department Visit and Hospitalization Rates, Missouri, 2000-2014
4 Asthma Emergency Department Visit Rates by Race, Missouri, 2000-2014
5 Asthma Hospitalization Rates by Race, Missouri, 2000-2014
Missouri Asthma Prevention and Control Program Page 6
Statewide Children < 15 Years of Age
6 Asthma Emergency Department Visit and Hospitalization Rates among Children < 15 years of
age, Missouri, 2000-2014
7 Asthma Emergency Department Visit Rates among Children by Age Group, Missouri, 2000-
2014
8 Asthma Hospitalization Rates among Children by Age Group, Missouri, 2000-2014
9 Asthma Emergency Department Visit Rates among Children < 15 years of age by Race,
Missouri, 2000-2014
10 Asthma Hospitalization Rates among Children < 15 years of age by Race, Missouri, 2000-2014
State and County Comparisons for Children < 15 Years of Age
11 Asthma Hospitalization Rates for Children < 15 years of age, Missouri and Dunklin County,
2002-2014
12 Asthma Emergency Department Visits for Children < 15 years of age, Missouri and Dunklin
County, 2002-2014
13 Asthma Hospitalization Rates for Children < 15 years of age, Missouri and Greene County,
2002-2014
14 Asthma Emergency Department Visit Rates for Children < 15 years of age, Missouri and
Greene County, 2002-2014
15 Asthma Hospitalization Rates for Children < 15 years of age, Missouri and Barton, Cedar and
Polk Counties, 2002-2014
16 Asthma Emergency Department Visit Rates for Children < 15 years of age, Missouri and
Barton, Cedar, and Polk Counties, 2002-2014
17 Asthma Hospitalization Rates for Children < 15 years of age, Missouri and Washington
County, 2002-2014
18 Asthma Emergency Department Visit Rates for Children < 15 years of age, Missouri and
Washington County, 2002-2014
19 Asthma Hospitalization Rates for Children < 15 years of age, Southwest Missouri and
Missouri, 2002-2014
20 Asthma Emergency Department Visit Rates for Children < 15 years of age, Southwest Missouri
and Missouri, 2002-2014
MO HealthNet Group Comparisons for Children < 19 Years of Age
21 Asthma Emergency Department Visit Rates among Three Groups of Children < 19 years of
age: MO HealthNet, Children’s Health Insurance Program, and Children without MO
HealthNet, Missouri, 2000-2014
22 Asthma Preventable Hospitalization Rates among Three Groups of Children < 19 years of age:
MO HealthNet, Children’s Health Insurance Program, and Children without MO HealthNet,
Missouri, 2000-2014
Smoking among Pregnant Women
23 The Prevalence of Smoking during Pregnancy, Missouri and United States, 1990-2014
Mortality
24 Asthma Mortality Rates by Race, Missouri, 2000-2014
Missouri Asthma Prevention and Control Program Page 7
Table 1. Asthma School Health Initiatives 1995-“Right to Carry” asthma medication in schools legislation passed 1999-First School Nurse Asthma Learning Sessions and Assessment of Need 2001-Centers for Disease Control and Prevention (CDC) Grant Addressing Asthma from a Public Health Perspective 2002-School Nurse Survey completed, Missouri Asthma Coalition and School Health Sub-committee Formed 2003-School Asthma Manual Workgroup formed 2004-Missouri School Asthma Manual and School Staff In-service DVD Completed; 900 nurses in asthma workshops since 1999 2005-School Asthma Manual and Staff In-service DVD Distribution to all school districts, Missouri School Board
Association School Board Member training and Disabling Asthma Survey completed 2006-2012 “Becoming an Asthma Educator and Care Manager” including In-Check dial and peak flow meter with more than 600
school nurses trained 2006-2007 Health Literacy project “Zoey and the Zones” 2006-2011 School Nursing Awards given to design and implement asthma control projects (299 awards in 68 counties) 2007 Asthma Quality Improvement project included in school health contract (over 50% of the school districts) 2008-2009 $7.5 million Missouri Foundation for Health Childhood Asthma Linkages in Missouri (CALM) grants awarded for
childhood asthma. 2010 Teaming Up for Asthma Control (TUAC) school intervention funded through CDC grant 2011 Missouri School Asthma Manual (2nd edition) released 2012 Section 167.635.1 (HB 1188) permits stock supply of asthma emergency medication in schools 2013 School Nurse Roundtable: St Louis Area with school nurse leaders from districts representing ~ 98,500 students 2014 Childhood Asthma Linkages in Missouri (CALM) 2 Initiative: Enhancing Asthma Care Outcomes via School Nurses with
eight school districts 2015 School nurses participating in Impact Asthma ECHO – Asthma Essentials
2016 Asthma Panel Risk Reports to assess asthma burden in school districts
Introduction
Asthma is a major chronic respiratory condition that may lead to disability and adversely affect quality
of life when not well controlled. In 2014, more than one-half million adults (9.7%) and children
(11.2%) were living with the condition in Missouri.1 Disparities also exist, with African-American
children having a significantly higher prevalence of asthma and associated morbidity.2 High
emergency department (ED) visit and hospitalization rates are indicators of uncontrolled asthma and
risk for future exacerbations. Although the causes of asthma are not well understood, improved
scientific understanding of the disease and treatments have led to substantial improvements in care and
treatment, making control possible for many people. Reaching health providers and families of
children with guideline-based management education is critical to control asthma symptoms and
reduce the risk of preventable exacerbations and deaths.
The Missouri Asthma Prevention and Control Program (MAPCP), established in 2001, is funded by
the Centers for Disease Control and Prevention (CDC) as part of the National Asthma Control Program
(NACP) with a strategic focus on Comprehensive Asthma Control through Evidence-based Strategies
and Public Health-Health Care Partnerships.3,4
The national program calls for states to strengthen and
expand asthma control efforts in school and home settings and to partner with healthcare organizations
and others to promote utilization and coverage for comprehensive asthma control services.5,6
The
MAPCP and partners have made substantial strides in improving asthma care and health outcomes.
Asthma and School Health
An ongoing focus has been educating and expanding the capacity of school nurses to provide
guideline-based care for students with asthma. From a community health intervention perspective,
schools represent a highly cost-effective setting in which to achieve the greatest impact in reducing
asthma related complications among school age children. School based initiatives in Missouri spanning
almost two decades are shown in Table 1.
Missouri Asthma Prevention and Control Program Page 8
Key Asthma Initiatives
The CDC’s $3.4 million investment in MAPCP over the first decade of the program’s existence has
generated more than $20 million in investments from other stakeholders.7 Key asthma partnership and
surveillance initiatives in Missouri include:
The Childhood Asthma Linkages in
Missouri (CALM) program, funded by
the Missouri Foundation for Health,
began in 2008 and extended across 14
urban and rural sites in Missouri with
project periods ranging from three to
five years.8,9,10
University of Missouri, Asthma Ready
Communities has provided asthma
training for > 3,600 participants
including physicians, nurse
practitioners, school nurses and
respiratory therapists since 2009 in an
effort to coordinate and improve
asthma care for school age children.11
The Early Childhood Asthma Initiative (ECAI) focused on preschool children with current
asthma and their families or caregivers through licensed childcare facilities utilizing the
statewide local public health agencies (LPHAs) network (May 2010). Sixty-seven ECAI
contracts covering 71 counties were awarded to LPHAs and 904 initial environmental
assessments were completed, individual asthma consultation services were provided to 659
families, and information about safe and healthy environments was provided to 3,175 childcare
facilities.12
Enhancing asthma medication profiles to improve asthma control: A drug utilization review
conducted by Medicaid initially in 200213
and repeated in 2013-2014 to improve asthma
medication regimens and reduce cost. The intervention included 670 physicians and 12,132
targeted patients.14
Initiation of asthma risk panel reports using Medicaid administrative claims data to identify
individuals with uncontrolled asthma (2014). To date, there have been 21 health centers
requesting and receiving patient panel asthma risk reports covering 11,163 children and 7,563
adults.15
Impact Asthma ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing
technology to form a learning interdisciplinary collaborative to improve asthma care with the
University of Missouri as the hub (Section 191.1140.1, 2015).16
State Plan Amendments to provide asthma preventive health services to Medicaid recipients
(self-management education and home assessments) and make pediatric asthma a stand-alone
condition to qualify for the Health Home program (2015-2016).17,18
Childhood Asthma Linkages in Missouri
Missouri Asthma Prevention and Control Program Page 9
Trends in Prevalence
In 2014, almost 10% of the adults in Missouri have current asthma, representing approximately
450,530 people. The prevalence of asthma among adults with the exception of 2008 is consistently
higher in Missouri than the U.S. (Figure 1). With the change in the weighting methodology and the
addition of cell phones, there is no clear trend in the adult asthma prevalence in Missouri from 2011 to
2014.
In 2014, approximately 152,000 (11.2%) Missouri children, 17 years of age and younger, had current
asthma (Figure 2). The Missouri childhood asthma prevalence has fluctuated since 2011 with no clear
trend for the four year period (2011-2014).
7.2
8.2 8.5
8.0
9.1 9.0 8.6 8.5 8.4
9.5
8.8 9.2
10.4 10.8
9.7
7.2 7.2 7.5 7.7
8.1 7.9 8.2 8.2
8.5 8.4 8.6 8.8 8.9 9.0 8.9
0
2
4
6
8
10
12
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Pe
rce
nt
Figure 1. Current Asthma Prevalence among Adults ≥ 18 years of age, Missouri and U.S.
MO
U.S.
Change in weighting and addition of cell phones
Source: Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. https://www.cdc.gov/asthma/brfss/default.htm
9.8
8.6
10.1 10.9
7.9
10.1
7.7
11.2
9.0 8.9 9.0 8.6 8.4
8.7
8.9
9.2
8.9
0
2
4
6
8
10
12
2006 2007 2008 2009 2010 2011 2012 2013 2014
Pe
rce
nt
Figure 2. Current Asthma Prevalence among Children ≤ 17 years of age, Missouri and U.S.
MO
U.S.
Change in weighting and addition of cell phones
Source: Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. https://www.cdc.gov/asthma/brfss/default.htm
Missouri Asthma Prevention and Control Program Page 10
Trends in Morbidity
The impact of the asthma prevention and control coordinated efforts was assessed using surveillance
data from the Missouri Department of Health and Senior Services (DHSS), Missouri Information for
Community Assessment (MICA), MO HealthNet (Medicaid) administrative claims data, and other
sources to explore asthma morbidity trends statewide and for selected areas with asthma champions.
Trends were assessed using linear regression and 95% confidence intervals.
I. Asthma Emergency Department Visits and Hospitalizations – All Ages
The age-adjusted asthma hospitalization rate decreased significantly from 12.4 (95% confidence
interval [CI], 12.1-12.7) in 2000 to 11.5 (95% CI, 11.2-11.8) per 10,000 population in 2014, with a
steady decline from 2008-2013 (Figure 3*). Overall, there has been no significant change in emergency
department (ED) visits among the state’s population during the same time period.
African Americans had significantly higher rates of asthma ED visits than whites (Figure 4*). There
has been a significant downward linear trend in asthma ED visit rates among whites from 2000 to
2014, whereas the rate for African Americans increased significantly from 17.6 (95% CI, 17.3-17.9) in
2000 to 18.5 (95% CI, 18.2-18.8) per 1,000 population in 2014.
* Age-adjustment using U.S. 2000 standard population. Missouri Information for Community Assessment (MICA).
12.4 12.7 13.2 13.9 13.5 13.8 13.2 13.0
13.9 13.6 13.4 12.4 12.0
10.8 11.5
5.4 5.5 5.7 5.6 5.1 5.2 5.0 5.2 5.2 5.2 5.3 5.2 5.7 5.2 5.5
0
2
4
6
8
10
12
14
16
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Age
-ad
just
ed
Rat
e
Figure 3. Asthma Emergency Department Visit and Hospitalization Rates, Missouri, 2000-2014
Hospitalization
ED Visits
Sources: Missouri Department of Health and Senior Services, Emergency Room MICA and Hospital Discharges Charges & Days of Care MICA; ED visit rates per 1,000 population; Hospitalization rates per 10,000 population.
3.4 3.7 3.7 3.8 3.4 3.5 3.2 3.4 3.3 3.2 3.1 3.1 3.2 3.0 3.0
17.6 16.6 17.3
16.5 15.3 15.3 15.4 15.9 16.1 16.2
17.0 16.7
19.4 17.5
18.5
0
5
10
15
20
25
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Age
-ad
just
ed
Rat
e p
er
1,0
00
Figure 4. Asthma Emergency Department Visit Rates by Race, Missouri, 2000-2014
White African American
Linear (White)
Regression 2000-2014: F(1,13) = 35.859, R2 = 0.7339 (adj R2 = 0.7135), p < 0.001 Source: Missouri Department of Health and Senior Services. Emergency Room MICA.
Missouri Asthma Prevention and Control Program Page 11
African Americans also consistently had significantly higher rates of asthma hospitalizations than
whites with a significant decline from 41.9 (95% CI, 40.4-43.5) in 2008 compared to 35.5 (95% CI,
34.1-36.9) per 10,000 population in 2014 (Figure 5*). Among whites, the age-adjusted asthma
hospitalization rate decreased significantly from 8.4 (95% CI, 8.1-8.7) in 2000 to 7.3 (95% CI, 7.0-7.5)
per 10,000 population in 2014, with a steady decline from 2008 to 2013.
II. Asthma Emergency Department Visits and Hospitalizations – Age 0 to 14
Among children younger than age 15, there has been a significant decline in asthma hospitalization
rates from 24.7 (95% CI, 23.8-25.6) in 2000 to 21.0 (95% CI, 20.1-21.8) per 10,000 population in 2014
(Figure 6). There was a significant decline in the ED visit rate from 11.1 (95% CI, 10.9-11.3) in 2000
to 9.6 (95% CI, 9.4-9.8) per 1,000 population in 2007 followed by a significant increase from 9.6 (95%
CI, 9.5-9.8) in 2008 to 11.2 (95% CI, 11.0-11.3) per 1,000 population in 2014 resulting in no
significant change in ED visits from 2000 to 2014.
* Age-adjustment using U.S. 2000 standard population. Missouri Information for Community Assessment (MICA).
8.4 9.1 9.4 10.3 10.2 10.0 9.4 9.2 9.4 9.2 9.1 8.0 7.6 7.0 7.3
37.0 34.8 35.6 36.3
34.3 37.0 37.2 36.7
41.9 39.7 40.0 39.2 38.3
33.7 35.5
0
5
10
15
20
25
30
35
40
45
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Age
-ad
just
ed
Rat
e p
er
10
,00
0
Figure 5. Asthma Hospitalization Rates by Race, Missouri, 2000-2014
White African American
Source: Missouri Department of Health and Senior Services. Hospital Discharges, Charges & Days of Care MICA.
11.1 10.5 11.4 10.5 9.9 9.8 9.8 9.6 9.6 9.9 10.6 10.6 11.5 10.4 11.2
24.7
21.2
23.7 23.1 22.8 21.7 22.1 21.9 22.6 23.1
22.0
19.5 20.5
17.2
21.0
0
5
10
15
20
25
30
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
R
ate
Figure 6. Asthma Emergency Department Visit and Hospitalization Rates among Children < 15 years of age, Missouri, 2000-2014
ED Visits Hospitalizations
Source: Missouri Department of Health and Senior Services. Emergency Room MICA and Hospital Discharges Charges & Days of Care MICA; ED visit rates per 1,000 population; Hospitalization rates per 10,000 population.
Missouri Asthma Prevention and Control Program Page 12
For children < age 1, there has been a significant decline in asthma ED visit rates from 10.9 (95% CI,
10.1-11.6) in 2000 to 4.6 (95% CI, 4.1-5.1) per 1,000 population in 2014 and a significant decline
among children aged 10 to 14 from 8.1 (95% CI, 7.8-8.4) to 7.4 (95% CI, 7.1-7.7) per 1,000 population
(Figure 7) for the same time period. However, there was a significant increase in the asthma ED visit
rate among children aged 5 to 9 years from 10.5 (95% CI, 10.2-10.8) in 2000 to 12.9 (12.5-13.2) per
1,000 population in 2014.
Regarding asthma hospitalization rates among children per 10,000 population, there have been
significant declining trends among three of the four age groups: < 1 year from 33.5 (95% CI, 29.6-
37.9) in 2000 to 8.5 (95% CI, 6.6-10.9) in 2014 with a downward trend from 2002 to 2013; 1 to 4 years
from 41.6 (95% CI, 39.4-44.0) in 2004 to 35.8 (95% CI, 33.7-38.0) in 2014; and 10 to 14 years from
14.7 (95% CI, 13.6-15.9) in 2000 to 11.0 (95% CI, 10.0-12.1) in 2014 (Figure 8). Among children
aged 5 to 9 years, there was a significant increase in the asthma hospitalization rate comparing 18.9
(95% CI, 17.5-20.3) in 2004 and 24.0 (95% CI, 22.5-25.6) in 2012.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
< 1 10.9 11.6 12.0 10.1 8.1 7.8 7.5 7.1 6.5 5.7 6.6 5.5 5.1 5.0 4.6
1 to 4 16.4 16.4 17.3 16.0 15.1 14.4 15.2 14.3 14.5 14.1 15.4 15.4 16.4 15.1 15.5
5 to 9 10.5 9.3 10.6 9.8 9.6 9.8 10.0 10.0 9.7 10.5 11.2 11.7 13.1 11.5 12.9
10 to 14 8.1 7.3 8.0 7.4 6.9 7.0 6.2 6.2 6.4 7.0 6.9 6.9 7.4 6.6 7.4
0
2
4
6
8
10
12
14
16
18
20
Rat
e p
er
1,0
00
Figure 7. Asthma Emergency Department Visit Rates among Children by Age Group, Missouri, 2000-2014
Source: Missouri Department of Health and Senior Services. Emergency Room MICA.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
< 1 33.5 37.5 43.2 32.2 28.4 23.9 20.2 19.4 18.3 14.8 15.9 12.0 8.6 8.0 8.5
1 to 4 39.7 38.6 41.4 41.5 41.6 38.0 41.4 39.3 40.8 41.0 37.6 32.7 31.5 30.2 35.8
5 to 9 22.3 16.1 18.6 18.9 18.9 20.1 20.2 20.7 20.0 22.5 21.6 20.4 24.0 17.8 22.0
10 to 14 14.7 10.6 12.3 12.2 11.9 10.9 10.0 10.4 11.8 11.3 11.4 9.8 10.8 8.2 11.0
0
5
10
15
20
25
30
35
40
45
50
Rat
e p
er
10
,00
0
Figure 8. Asthma Hospitalization Rates among Children by Age Group, Missouri, 2000-2014
Source: Missouri Department of Health and Senior Services. Hospital Discharges Charges & Days of Care MICA.
Missouri Asthma Prevention and Control Program Page 13
Among white children younger than age 15, there was a significant decline in the asthma ED visit rate
from 5.8 (95% CI, 5.6-5.9) in 2000 to 4.8 (95% CI, 4.7-5.0) in 2014 per 1,000 population (Figure 9)
and in the hospitalization rate from 14.0 (95% CI, 13.3-14.8) to 11.0 (95% CI, 10.4-11.7) per 10,000
population for the same time period (Figure 10). There was a significant declining trend in the asthma
ED visit rate among African-American children between 2000 (38.2; 95% CI, 37.3-39.1) and 2007
(30.7; 95% CI, 29.9-31.5) followed by a significant upward trend comparing 2008 (30.7; 95% CI,
29.9-31.5) to 2014 (39.2; 95% CI, 38.3-40.1) per 1,000 population (Figure 9).
The asthma hospitalization rate among African-American children decreased significantly from 78.0
(95% CI, 74.0-82.2) to 60.2 (95% CI, 56.7-63.9) per 10,000 from 2000 to 2014 (Figure 10). In
addition, there has been a 23.1% decrease in the disparity for asthma hospitalizations between white
and African-American children.
5.8 5.9 6.3 6.0 5.7 5.6 5.2 5.1 5.2 5.2 5.2 5.3 5.4 4.8 4.8
38.2
33.6
36.5
32.9 30.5 30.1
31.8 30.7 30.7 32.0
34.8 34.6
39.3
35.1
39.2
0
5
10
15
20
25
30
35
40
45
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
e p
er
1,0
00
Figure 9. Asthma Emergency Department Visit Rates among Children < 15 years of age by Race, Missouri, 2000-2014
White African American
Source: Missouri Department of Health and Senior Services. Emergency Room MICA>
14.0 13.6 15.4 14.6 15.3 13.8 13.6 13.9 12.6 13.5 12.7 9.8 11.0 9.5 11.0
78.0
58.8 63.9 64.1
58.6 58.7 60.8 57.9
68.2 65.8 62.2 61.8 62.0
46.9
60.2
0
10
20
30
40
50
60
70
80
90
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
e p
er
10
,00
0
Figure 10. Asthma Hospitalization Rates among Children < 15 years of age by Race, Missouri, 2000-2014
White African American
Source: Missouri Department of Health and Senior Services. Hospital Discharges Charges & Days of Care MICA.
Missouri Asthma Prevention and Control Program Page 14
III. County Asthma Initiatives
The MAPCP established a county-wide systems-based asthma program in Dunklin County that
addressed asthma through linking schools, hospitals, clinics, and child care facilities. The Kennett
School District asthma project in Dunklin County was initiated in 2001 with the county-wide initiative
beginning in 2007. There has been a significant decline in the asthma hospitalization rate in Dunklin
County from 2002 to 2006, declining at a faster rate after 2007 to 2009 among children aged < 15
years (Figure 11). Since 2009, the asthma hospitalization rates have fluctuated but the 2014 rate of
37.0 (95% CI, 23.9-54.6) remained significantly below the 2002 rate of 160.4 (95% CI, 132.3-192.7)
per 10,000 population.
Although the asthma ED visit rates among children in Dunklin County were consistently below the
state rates, there was a significant increasing trend between 2009 and 2012 (6.2; 95% CI, 4.5-8.4 vs
10.9; 95% CI, 8.6-13.7) in the County (Figure 12).
23.7 23.1 22.8 21.7 22.1 21.9 22.6 23.1 22.0 19.5 20.5 17.2 21.0
160.4
113.5
101.3
88.0 77.8 75.7
53.3
34.1
49.1 39.6
21.8 30.5
37.0
0102030405060708090
100110120130140150160170
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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,00
0
Figure 11. Asthma Hospitalization Rates for Children < 15 years of age , Missouri and Dunklin County, 2002-2014
Missouri
Dunklin County
County-wide Initiative launched
Source: Missouri Department of Health and Senior Services. Hospital Discharges Charges & Days of Care MICA.
Missouri Foundation for Health CALM Project Kennett Public Schools
11.4 10.5 9.9 9.8 9.8 9.6 9.6 9.9
10.6 10.6 11.5
10.4 11.2
7.6 8.1 9.4
8.5 7.0
9.2
7.3 6.2
8.6 10.0
10.9 9.4 9.2
0
2
4
6
8
10
12
14
16
18
20
22
24
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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1,0
00
Figure 12. Asthma Emergency Department Visits for Children < 15 years of age, Missouri and Dunklin County, 2002-2014
Missouri Dunklin CountyCounty-wide
Initiative launched
Source: Missouri Department of Health and Services. Emergency Room MICA.
Missouri Foundation for Health CALM Project Kennett Public Schools
Missouri Asthma Prevention and Control Program Page 15
Among children younger than age 15, the asthma hospitalization (Figure 13) and ED visit (Figure 14)
rates in Greene County have been consistently below the state rates. In addition, although there was a
spike in 2007, there has been a significant decline in asthma hospitalizations in Greene County from
16.2 (95% CI, 12.7-20.4) in 2002 to 8.9 (95% CI, 6.5-12.0) per 10,000 population in 2013.
There has also been a significant decline in ED visits in Greene County from 6.4 (95% CI, 5.7-7.2) in
2002 to 4.4 (95% CI, 3.9-5.1) per 1,000 population in 2014.
23.7 23.1 22.8 21.7 22.1 21.9 22.6 23.1 22.0 19.5 20.5
17.2
21.0
16.2
13.0 15.0
13.2 12.2
18.1
8.4 10.9 11.3
5.7
10.7 8.9
13.1
0
10
20
30
40
50
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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10
,00
0
Figure 13. Asthma Hospitalization Rates for Children < 15 years of age, Missouri and Greene County, 2002-2014
Missouri
Greene
Linear (Greene)
Regression 2002-2013: F(1,10) = 9.0194, R2 = 0.4742 (adj R2 = 0.4216), p = 0.01 Source: Missouri Department of Health and Senior Services. Hospital Dischages, Charges, and Days of Care MICA .
Missouri Foundation for Health CALM Project School District of Springfield
11.4 10.5
9.9 9.8 9.8 9.6 9.6 9.9 10.6 10.6
11.5 10.4
11.2
6.4 5.0 4.8
5.5 4.6
6.4 5.4
6.1 7.3 7.3
5.9
4.0 4.4
0
2
4
6
8
10
12
14
16
18
20
22
24
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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1,0
00
Figure 14. Asthma Emergency Department Visit Rates for Children < 15 years of age, Missouri and Greene County, 2002-2014
Missouri Greene
Source: Missouri Department of Health and Senior Services. Emergency Room MICA
Missouri Foundation for Health CALM Project School District of Springfield
Missouri Asthma Prevention and Control Program Page 16
The Barton County Memorial Hospital CALM project began in 2009 and was implemented through
2014. Asthma services were primarily delivered in Barton, Cedar, and Polk counties. Although the
asthma hospitalization rates with the exception of 2004 are below the state rates, there were less than
20 cases for 10 of the 13 years which make the rates unstable and fluctuate widely with no clear trend
(Figure 15).
There was a decline in asthma ED visit rates for the three combined counties from 7.7 (95% CI, 6.2-
9.5) in 2003 to 4.8 (95% CI, 3.6-6.2) per 1,000 population in 2008 but was not statistically significant
(Figure 16). From 2010 to 2014 the ED visit rates have fluctuated with no significant trend.
23.7 23.1 22.8 21.7 22.1 21.9 22.6 23.1 22.0 19.5 20.5
17.2
21.0
13.3
17.4
23.5
9.4 9.4
13.6 15.4
7.7
17.2
7.9 8.8 11.6 10.9
0
10
20
30
40
50
2002* 2003 2004 2005* 2006* 2007* 2008* 2009* 2010 2011* 2012* 2013* 2014*
Rat
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10
,00
0
Figure 15. Asthma Hospitalization Rates for Children < 15 years of age, Missouri and Barton, Cedar, and Polk Counties, 2002-2014
Missouri
Barton-Cedar-Polk CountiesMissouri Foundation for Health CALM Project Barton County Memorial Hospital
Source: Missouri Department of Health and Senior Services. Hospital Discharges, Charges, and Days of Care MICA. *< 20 events in the combined counties, rate unstable.
11.4 10.5 9.9 9.8 9.8 9.6 9.6 9.9
10.6 10.6 11.5
10.4 11.2
7.7 7.7 7.6 7.5 7.3 5.7
4.8
6.7 7.5
5.3
7.0 5.5
6.3
0
2
4
6
8
10
12
14
16
18
20
22
24
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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Figure 16. Asthma Emergency Department Visit Rates for Children < 15 years of age, Missouri and Barton, Cedar, and Polk Counties, 2002-2014
Missouri
Barton-Cedar-Polk Counties
Source: Missouri Department of Health and Senior Services. Hospital Discharges, Charges, and Days of Care MICA.
Missouri Foundation for Health CALM Project Barton County Memorial Hospital
Missouri Asthma Prevention and Control Program Page 17
There were less than 20 asthma hospitalizations per year among children age 14 and younger in
Washington County so the rates have fluctuated and are unstable (Figure 17).
Among children younger than 15 years of age, there was a fast and significant decline in the asthma
ED visit rates per 1,000 population in Washington County between 2002 and 2004 (20.3; 95% CI,
16.6-24.6 vs 11.0; 95% CI 8.3-14.4). With the exception of an increase in 2005, the decline continued
to 2008 (5.9; 95% CI 4.0-8.5). Although the rates increased from 2011 to 2014 (not significantly),
overall there has been a significant decline in asthma ED visit rates among children in Washington
County between 2002 and 2014 (10.2; 95% CI, 7.5-13.5) with the rate reduced by almost one-half
between these years (Figure 18).
23.7 23.1 22.8 21.7 22.1 21.9 22.6 23.1
22.0
19.5 20.5
17.2
21.0
11.9 14.0
28.1
10.2
20.1
10.0
5.9
10.1
14.0
10.1
18.4
18.5
4.2 0
5
10
15
20
25
30
2002* 2003* 2004* 2005* 2006* 2007* 2008* 2009* 2010* 2011* 2012* 2013* 2014*
Rat
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10
,00
0
Figure 17. Asthma Hospitalization Rates for Children < 15 years of age, Missouri and Washington County, 2002-2014
Missouri Washington County
Source: Missouri Department of Health and Senior Services. Hospital Discharges, Charges, and Days of Care. *< 20 events in the county, rates unstable.
Missouri Foundation for Health CALM Project Washington County Memorial Hospital
County Initiative launched
11.4 10.5
9.9 9.8 9.8 9.6 9.6 9.9 10.6 10.6
11.5 10.4
11.2
20.3
18.0
11.0 12.5
7.3 6.4 5.9
7.1 8.4
6.5 7.8
8.8
10.2
0
2
4
6
8
10
12
14
16
18
20
22
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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1,0
00
Figure 18. Asthma Emergency Department Visit Rates for Children < 15 years of age, Missouri and Washington County, 2002-2014
Missouri Washington County
Source: Missouri Department of Health and Senior Services. Emergency Room MICA.
Missouri Foundation for Health CALM Project Washington County Memorial Hospital
County Initiative launched
Missouri Asthma Prevention and Control Program Page 18
Among children age 14 and younger, the asthma hospitalization rates in the combined six counties of
SW Missouri were consistently below the state rates. In this geographical area, there was a significant
decline in asthma hospitalization rates from 18.7 (95% CI, 15.4-22.6) in 2002 to 12.2 (95% CI, 9.5-
15.3) per 10,000 in 2005 with a further steady decline from 2006 to 2011 resulting in an overall
significant decline from 2002 to 2014 (10.2; 95% CI, 7.8-13.1)(Figure 19).
The asthma ED visit rates in the combined six counties in SW Missouri were also consistently below
the state rates with the exception of 2007, with a significant decline from 9.3 (95% CI, 8.5-10.1) in
2002 to 5.6 (95% CI, 5.1-6.3) per 1,000 population in 2014. (Figure 20).
23.7 23.1 22.8 21.7 22.1 21.9 22.6 23.1 22.0 19.5 20.5
17.2
21.0
18.7 18.5 16.0
12.2
16.0 14.9 13.4
11.1 10.6 10.5 11.2 8.3
10.2
0
10
20
30
40
50
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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10
,00
0
Figure 19. Asthma Hospitalization Rates for Children < 15 years of age, Southwest Missouri* and Missouri, 2002-2014
Missouri SW Missouri
*Barry, Barton, Jasper, Lawrence, McDonald and Newton Counties.
Source: Missouri Department of Health and Senior Services. Hospital Discharges, Charges, and Days of Care.
Missouri Foundation for Health CALM Project Barton County Memorial Hospital and Cox Monett Hospital, Inc.
11.4 10.5
9.9 9.8 9.8
9.6
9.6 9.9 10.6 10.6
11.5
10.4 11.2
9.3 8.6
8.2 8.3 8.5
9.9
7.7 7.0 6.7
8.0 8.2
5.8 5.6
0
2
4
6
8
10
12
14
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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1,0
00
Figure 20. Asthma Emergency Department Visit Rates for Children < 15 years of age, Southwest Missouri* and Missouri, 2002-2014
Missouri SW Missouri
*Barry, Barton, Jasper, Lawrence, McDonald, and Newton counties.
Source: Missouri Department of Health and Senior Services. Emergency Room MICA
Missouri Foundation for Health CALM Project Barton County Memorial Hospital and Cox Monett Hospital, Inc.
Missouri Asthma Prevention and Control Program Page 19
IV. MO HealthNet (Medicaid) and the Children’s Health Insurance Program
The Missouri Department of Social Services (DSS) provides health care for uninsured children through
the Children’s Health Insurance Program (CHIP). In 2007, Missouri's CHIP began operating as a
combination Medicaid/CHIP program, entitled MO HealthNet for Kids.19
The program provides health
insurance for children 0 to 18 years of age with premiums for families with incomes greater than 150%
of the federal poverty level (FPL), except for families with infants < 1 year of age are not subject to
premiums unless their family income exceeds 196% FPL.
From 2000 to 2014, asthma ED visits for the CHIP population decreased by 5.4% and decreased by
13.8% for the MO HealthNet (Medicaid children) population (Figure 21). For the same time period,
the asthma ED visits for the non-MO HealthNet group decreased by 12.7%. In 2014, the CHIP asthma
ED visit rate of 12.6 per 1,000 children remained 26% higher than the national benchmark of 10
asthma ED visits per 1,000 children.
21.7
18.5
19.9
18.0
16.0 16.6
17.3 17.2 16.3
17.5 18.5
17.8
19.3
17.5 18.7
13.3
11.4
13.3 12.3
10.1 11.3
11.9 12.4 13.3
14.8 14.1
12.4
13.9 12.7 12.6
5.5 5.2 5.4 5.1 5.3 5.0 4.8 4.5 4.7 4.5 4.1 4.4 4.9 4.3 4.8
10 10 10 10 10 10 10 10 10 10 10 10 10 10 10
0
5
10
15
20
25
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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00
po
pu
lati
on
Figure 21. Asthma Emergency Department Visit Rates among Three Groups of Children < 19 years of age: MO HealthNet, Children's Health Insurance Program, and
Children without MO HealthNet, Missouri, 2000-2014
MO HealthNet
CHIP
Non-MO HealthNet
U.S. Benchmark
Source: Missouri Department of Social Services. Missouri Children’s Health Insurance Program (CHIP) and Show Me Healthy Babies Annual Report 2016
Missouri Asthma Prevention and Control Program Page 20
From 2000 to 2014, there was a significant decrease in asthma preventable hospitalizations among MO
HealthNet (Medicaid children) population (-34.8%, p < 0.001) and for the non-MO HealthNet group (-
18.2%) (Figure 22).*20,21,22
Preventable asthma hospitalizations for the CHIP population decreased by
39.0%. In 2014, the CHIP preventable hospitalization rate of 1.7 per 1,000 children was 24% lower
than the national benchmark rate of 2.25 asthma preventable hospitalizations per 1,000 children. The
MO HealthNet population remained 33% higher than the national benchmark.
* Preventable hospitalizations (also called ambulatory care sensitive conditions) are “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, or managing a chronic disease or condition...”
4.6
3.6
3.9 3.7
3.4 3.2
3.4 3.4 3.2
3.5
3.0 2.9 2.9
2.4
3.0 2.8
2.1 1.9
2.1 1.8
1.6 1.6 1.9
2.4
2.9
2.0 2.0 2.1
1.6 1.7
1.1 0.9 1.0 0.9 1.0 1.0 1.0 0.9 1.0
0.8 0.9 0.7
0.9 0.7
0.9
2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25 2.25
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rat
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po
pu
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on
Figure 22. Asthma Preventable Hospitalization Rates among Three Groups of Children < 19 years of age: MO HealthNet, Children's Health Insurance Program, and
Children without MO HealthNet, Missouri, 2000-2014
MO HealthNet
CHIP
Non-MO HealthNet
U.S. Benchmark
Linear (MOHealthNet)
Regression 2000-2014: F(1,13) = 35.042, R2 = 0.7294 (adj R2 = 0.7086), p < 0.001 Source: Missouri Department of Social Services. Missouri Children’s Health Insurance Program (CHIP) and Show Me Healthy Babies Annual Report 2016
Missouri Asthma Prevention and Control Program Page 21
IV. Asthma Risk Factor – Smoking among Pregnant Women
As shown in figures 7 and 8, for children < age 1 from 2000 to 2014, there have been significant
declining trends in asthma ED visits and hospitalizations. Likely contributing to the declines is the
significant decline in smoking among pregnant women in Missouri and in the United States. In
Missouri, smoking among pregnant women declined from 24.8% (95% CI, 24.4%-25.0%) in1990 to
16.7% (95% CI, 16.3%-16.9%) in 2014 ( (Figure 23). Nevertheless, the prevalence of smoking among
pregnant women in Missouri remains almost twice that of the U.S. in 2014 (16.7% vs 8.4%).
Health Outcomes Evaluations
The MAPCP and partners conduct quality improvement process and health outcomes studies. These
studies have contributed to further improving asthma care and control among children. The MAPCP
has launched evaluations of two large scale asthma control strategies: The Early Childhood Asthma
Initiative and Teaming Up for Asthma Control. The ECAI provided asthma control training, tools, and
equipment to staff in local public health agencies (LPHAs) statewide. The staff provided information
to childcare centers on indoor air quality assessments and asthma triggers and education to families on
in-home air quality and asthma management in pre-school children. The objective of this study was to
assess the outcomes of participation in this initiative for educators, children and child care facilities.
TUAC is a work force development intervention aimed at promoting school nurse competency for
assessing and caring for students with asthma. This project addresses a critical need – asthma control is
impeded because children are not receiving asthma status assessments and education for self-care as
often as needed. The aim is to improve asthma control by increasing asthma monitoring by school
nurses trained in asthma management, promoting asthma literacy using culturally appropriate material
and messages, and enhancing self-care behaviors among students (grades K to 6) with persistent
asthma and their families. These interventions have shown participants to have improved lung
function, inhalation technique, psychosocial indicators, and use of control medication (i.e., inhaled
corticosteroids); and reduced impairment and tobacco smoke exposure.12,23
In addition, for children
enrolled in TUAC and MO HealthNet, there was a decline in the 12-month total health care utilization
cost.23
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Missouri 24.8 24.2 23.4 22.1 20.7 20.2 19.7 19.6 19.1 18.3 18.3 18.4 18.2 18.1 18.2 18.3 18.4 17.8 17.6 16.9 18.9 18.3 18.1 17.6 16.7
United States 18.4 17.7 16.9 15.8 14.6 13.9 13.6 13.2 12.9 12.6 12.2 12.0 11.4 10.7 10.9 10.1 10.0 10.4 9.7 9.3 9.2 9.0 8.7 8.5 8.4
24.8 24.2 23.4
22.1 20.7 20.2 19.7 19.6 19.1
18.3 18.3 18.4 18.2 18.1 18.2 18.3 18.4 17.8 17.6 16.9
18.9 18.3 18.1 17.6 16.7
18.4 17.7
16.9 15.8
14.6 13.9 13.6 13.2 12.9 12.6 12.2 12.0 11.4
10.7 10.9 10.1 10.0 10.4
9.7 9.3 9.2 9.0 8.7 8.5 8.4
0
5
10
15
20
25
30
Pe
rce
nt
Figure 23. The Prevalence of Smoking during Pregnancy, Missouri and United States, 1990-2014
Missouri United States
Sources: Missouri Department of Health and Senior Services. Birth MICA. http://health.mo.gov/data/mica/BirthMICA/index.html and U.S. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics. http://wonder.cdc.gov/natality-current.html
Missouri Asthma Prevention and Control Program Page 22
Mortality
In 2014, 85 people died with asthma as the underlying cause for an age-adjusted asthma death rate of
1.3 per 100,000 people. Five of the 85 deaths were children younger than age 15. The mortality rate
was highest among individuals 65 years of age and older at 2.7 per 100,000 population. Women had a
slightly higher rate than men (1.5 versus 1.1 per 100,000 population), but the difference was not
statistically significant. There has been a significant decline in asthma mortality rates among whites
from 1.1 (95% CI, 0.8-1.4) in 2000 to 0.5 (95% CI, 0.3-0.7) per 100,000 population in 2011. There has
also been a decline but not significant in asthma mortality among African Americans from 5.1 (95%
CI, 3.3-7.4) in 2000 to 4.4 (95% CI, 3.0-6.3) per 100,000 in 2014, although for several years (2005-
2007, 2011 and 2013) there were less than 20 deaths among African Americans resulting in unstable
rates. However, in 2014 significantly more African-Americans died of asthma than whites, 4.4 (95%
CI, 3.0-6.3) versus 0.9 (95% CI, 0.6-1.1) per 100,000 population. Among all groups combined, there
was a significant decline in asthma mortality between 2000 (1.4; 95% CI, 1.2-1.8) and 2013 (0.8; 95%
CI, 0.6-1.0) per 100,000 population (Figure 24*).
Conclusion
Reducing the morbidity associated with asthma remains a significant public health challenge in
Missouri and in the nation. The progress toward reducing the burden of asthma is demonstrated in the
overall decline in asthma hospitalizations, disparities, and deaths in Missouri, but more needs to be
done with substantial disparities persisting. Progress has been shown in outcomes with both the Early
Childhood Asthma Initiative and Teaming Up for Asthma Control having shown improved health care
coordination and health outcomes among children with asthma. In addition, the asthma interventions
are reducing overall asthma hospitalizations across the State of Missouri, emergency department visits
in some areas with asthma champions, and health care utilization costs among pediatric populations.
Long-term progress in reducing the burden of asthma will require continued efforts, support, public
health – health care partnerships, and widespread collaborations with stakeholders, policy and decision
makers, health agencies, insurers, and other programs. Community, state, and national efforts to
promote comprehensive asthma control continue to be essential to reduce the burden, disparities, and
costs of asthma.
* Age-adjustment using U.S. 2000 standard population. Missouri Information for Community Assessment (MICA).
2000 2001 2002 2003 2004 2005* 2006* 2007* 2008 2009 2010 2011* 2012 2013* 2014
White 1.1 1.0 1.2 1.0 1.1 0.9 0.9 0.9 0.9 0.9 0.9 0.5 0.9 0.6 0.9
African American 5.1 4.2 3.8 4.2 3.1 2.6 2.2 2.7 3.6 3.6 3.1 2.8 2.9 2.6 4.4
All 1.4 1.4 1.5 1.3 1.3 1.1 1.0 1.2 1.2 1.3 1.2 0.8 1.1 0.8 1.3
0
1
2
3
4
5
6
Age
-ad
just
ed
Rat
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10
0,0
00
Figure 24. Asthma Mortality Rates by Race, Missouri, 2000-2014
Year* - Less than 20 deaths among African Americans rate is unstable. Source: Missouri Department of Health and Senior Services. Death Missouri Information for Community Assessment.
Missouri Asthma Prevention and Control Program Page 23
References
1 Centers for Disease Control and Pvention. 2014 Asthma Data: BRFSS Prevalence Tables and Maps. Retrieved January 27, 2017,
from https://www.cdc.gov/asthma/brfss/2014/default.htm 2 Missouri Department of Health and Senior Services. Asthma in Missouri 2014. Jefferson City, MO: Missouri Asthma Prevention
and Control Program, 2016. Retrieved January 27, 2017, from
http://health.mo.gov/living/healthcondiseases/chronic/asthma/pdf/MO.pdf 3 Homan, S., Gaddy, P., & Armbrecht, E. (n.d.). Putting excellent asthma care within reach (2010-2014). Retrieved January 28,
2017, from http://health.mo.gov/living/healthcondiseases/chronic/asthma/pdf/asthmastateplan.pdf 4 Centers for Disease Control and Prevention. National Asthma Control Program. Retrieved January 28, 2017, from
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Healthcare Financing of Healthy Homes Services: Medicaid Reimbursement for Home-Based Asthma Services in Missouri.
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Asthma from a Public Health Perspective” Grantees. CS257875 Atlanta, GA: National Center for Environmental Health, Division
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Vital Signs: Asthma in the United States. Retrieved from
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REPORT-2014.pdf 9 Carpenter LM, Lachance L, Wilkin M, Clark NM. Sustaining school-based asthma interventions through policy and practice
change. J Sch Health. 2013;83(12):859-66. doi: 10.1111/josh.12104. 10
Missouri Foundation for Health. CALM by the Numbers 2017. Retrieved January 28, 2017, from https://mffh.org/calm-by-the-
numbers/ 11
University of Missouri. Asthma Ready Communities. Columbia, MO: School of Medicine, Division of Child Health. Retrieved
January 28, 2017, from http://asthmaready.org/ 12
Homan S, Gaddy P, Yun S, Armbrecht E, Francisco B, Rood T. Changing the Trajectory of Asthma Morbidity through an Early
Childhood Asthma Initiative in Missouri. Retrieved January 28, 2017, from http://asthmaready.org/wp-
content/uploads/2014/02/ECI-AAE-Poster-2013.pdf 13
Heil B, Shields KM, Kenkel JL. DUReport: Asthma Therapy Guidelines 2002.University of Missouri-Kansas City Drug
Information Center. Retrieved January 28, 2017, from https://dss.mo.gov/mhd/cs/pharmacy/pdf/dur8-2.pdf 14
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