Current DHHS Activities: Tracking the Disease
Surveillance - the systematic collection, evaluation, and dissemination of data used to track the occurrence and severity of particular diseases - is critical to research and public health practice. Combined with studies in large groups of people, surveillance results can identify populations with particularly high or low prevalence, and can shed light on factors influencing the develop-ment of asthma. Surveillance data can help identify high risk populations and risk factors to inform the design and implementation of interventions suitable for a particular community. Finally, state and local health agencies can use surveillance information to assess the impact of public health programs or environmental controls.
Surveillance for Asthma
National estimates for asthma are developed from ongoing general health surveys. CDC is collaborating with NIH and EPA to sponsor more localized surveillance activities in four states and two major cities.
Current surveillance for asthma provides national estimates, but cannot provide state or local level data on asthma. The national estimates are derived from ongoing health surveys (9) and data systems dealing with health events such as mortality, hospitalization, emergency room visits, and outpatient visits. Th is information does not reveal the detailed picture of how asthma varies from one location to another-information greatly needed for an effective public health response. Fewer than 10 states have conducted asthma prevalence surveys (89). Surveillance for occupational asthma is also limited. Since1987, NIOSH has provided funding to several state health departments to pilot case-based surveillance for selected occupational health conditions, including asthma. Currently, four states are conducting surveillance and preventive intervention programs for occupational asthma (90). In Fiscal Year 1999, NIH, CDC and EPA took an initial step toward addressing these limitations. They initiated a collaborative project to define ongoing surveillance activities and their utility in asthma control efforts. The activities were undertaken in four states and two city health departments.
Urgent Need: Tracking the Disease
Establish coordinated and systematic local, state and national systems for asthma surveillance. Timely data on asthma at the state and local level are needed to support the design of effective public health interventions . Such data are critical to finding answers to the troubling question, "Why is asthma prevalence rising?" Better data will also enable us to target populations in significant need of public health intervention, and to assess the geographic, ethnic, and gender differences in asthma morbidity and mortality . Furthermore, information about other aspects of the burden of asthma would be useful in designing interventions, including the quality of care or the severity of illness. Finally, surveillance data are needed to determine whether or not public health programs are succeeding in reducing the impacts of asthma.
Existing state-based surveys should be expanded to include questions related to asthma diagnosis, severity, management techniques, and suspected environmental and household risk factors. Also, DHHS could provide additional assistance to states to use existing data more effectively. In many cases, information is not analyzed or made accessible to those who plan asthma interventions. Finally, new systems of surveillance should be developed to gather additional information on locations with particularly elevated rates of asthma. One potential area for model surveillance in both urban and rural settings is in emergency rooms, where many children with asthma receive care for an acute episode, but fail to receive follow-up care. In addition, strategies to determine the incidence of asthma, at least in defined geographic areas, are needed.
Current DHHS Activities: Evaluations of Asthma Programs (10)
Evaluations of public health programs and health services addressing asthma can speed progress towards widespread establishment of programs that allow people with asthma to live fully active lives. Many of the major public health and health services programs sponsored by DHHS have evaluation components to determine whether they are effective. The NAEPP and HRSA's Health Centers, for example, include evaluation elements to prompt shifts when programs are not meeting their goals, and to make possible replication of successful projects and components. AHRQ is developing new measures to help evaluate systematic improvements in quality of care. Valid, sensitive measures allow investigators to reliably identify those interventions that lead to real improvements. Recently AHRQ and NAEPP helped develop a new measure of quality care to track the use of anti-inflammatory medications. This measure will be used in the most recent version of the Health Plan Employer Data and Information Set (HEDIS 2000), a system widely used to evaluate the quality of health plans.
Research aimed at developing effective public health programs by definition provides evaluative information that helps determine what kinds of interventions work. For example, the Inner-City Asthma Study investigates not only the impact on asthma severity of reducing exposure to allergens and receiving proper medical care, but also the role of physician education and feedback in supporting the management of asthma.
Urgent Needs: Evaluation of Asthma Programs
Evaluate public health and health services interventions. Disseminate results. While some programs that educate patients and families about asthma management have been rigorously evaluated, most local and regional asthma coalition efforts that mobilize the broader community have not. To rapidly extend primary care and public health programs so that large numbers of asthma patients receive quality care, public health practitioners need to understand the characteristics of successful programs implemented in a variety of settings. Strengthening three aspects of evaluation could enhance the knowledge base about how to cost-effectively scale up public health programs and ensure that they significantly reduce rates of morbidity and mortality from asthma.
First, there is a need for appropriate tools to evaluate the effectiveness of asthma intervention strategies. Second, there is a need to build in an evaluation component, and sufficient funding to support it, to all public health programs that address asthma (11).
Third, there is a need to disseminate evaluations of asthma programs and encourage the use of such evaluations in designing and funding programs. Evaluation analyses combined with relevant research findings will help delineate determinants of success and failure in reducing the burden of asthma.