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Good News About Asthma


A mural in Greenpoint, Brooklyn

If you are like me, you missed an amazing bit of data buried in a New York Times article about the widening gap between the city’s rich and poor on a range of chronic illness.

A couple of weeks ago, the Times reported that asthma hospitalization rates “plummeted” in the last decade. That news would have been easy to miss. The article was headlined, "Gap in Illness Rates Between Rich and Poor New Yorkers Is Widening, Study Shows" and reported on a study by the New York City comptroller, William Thompson, Jr., which showed that children went to the hospital for asthma emergencies far less frequently in 2005 than in 1995.

(Special thanks here go to Carbon Tax Center co-founder and master number cruncher Charlie Komanoff for bringing the story to my attention, with kudos to community activist Ed Ravin and some of my Natural Resources Defense Council colleagues for many helpful insights that also inform this article.)

Here are the key data points: Children in the poorest sixth of the city, in terms of neighborhood median household income, saw their asthma hospitalization rate plummet by 47.4 percent. In the next half of neighborhoods, the rate dropped by 55.3 percent.

To put it another way: In the poorest third of the city, half as many kids went to the hospital because of an asthma attack in 2005 than in 1995.

This is amazing news. As somebody who has spent most of the past 15 years working to reduce diesel pollution, I’m stunned. And, as somebody who watches how the media covers health and the environment very closely, I’m equally stunned at the lack of media coverage about this kernel of the story. (Let’s face it: A gap in diabetes rates between East 63rd Street and East 103rd Street is no longer, regrettably, “Man bites dog.” But cutting the number of kids going to the emergency room for asthma — in the city’s poorest neighborhoods — surely is.)

Behind the Story

How has this drop in child asthma hospitalization rates happened?

Of course, parents, children, doctors and nurses deserve the lion’s share of credit for their response, across the board, to the asthma epidemic that hit New York City and other cities in the past two decades. Kids got sick, parents got involved, and doctors and nurses figured out better ways to treat asthmatic children.

But smarter policy choices are contributing too, by reducing the known triggers of asthma emergencies. We don’t know what “causes” asthma, but we do know that many commonly found substances can trigger an asthma episode. For example, we know that ultra fine particles in diesel exhaust can trigger an asthma attack.

Cleaner Buses, Cleaner Air

Over the past decade, New York City Transit invested hundreds of millions of dollars in new, cleaner diesel, natural gas and hybrid-electric buses that are equipped with the most advanced, state-of-the-art pollution controls. The transportation authority sped up the retirement of hundreds of old, two-stroke diesel buses that lacked any meaningful pollution controls, putting them out of service in some cases, up to six years ahead of the normal schedule. As a result, the fleet’s buses are 97 percent cleaner than they were in 1995.

So, while our region still fails to meet federal Environmental Protection Agency health standards for ground-level ozone and particulate soot pollution, diesel soot levels have been dramatically reduced where it counts most — on the sidewalks of many New York City neighborhoods, including the low-income areas and communities of color that have housed NYC Transit bus depots for decades.

The Great Unknowns

Asthma hospitalization rates, though, are clearly dropping faster than our pollution levels.

Why?

I don’t know. But a few questions, if answered, may help us understand what’s going on.

First, what has been the role of community-based health facilities and mobile medical units, both of which are far more prevalent than they were a decade ago? Are there fewer asthmatic kids—or are they just being treated close to home and not in hospital emergency rooms?

Second, what has changed in the drugs being prescribed and in the frequency of those prescriptions? Are children taking more effective drugs for asthma conditions? If so, that would suggest asthma rates remain the same but that asthma treatment is working. If fewer children are taking drugs, that could mean that asthma itself has actually dropped.

Third, has anything changed in the diagnoses being handed out? A personal example: A couple of years ago, my infant son had a breathing emergency that led him to the hospital. During the epic that followed, I asked several of the healthcare professionals I met whether he had asthma. Across the board, their response could be paraphrased as, “it depends how you define asthma.” In other words, some doctors would have looked at my son and checked the box marked “asthma.” Others would have diagnosed an allergic reaction and taken a more wait-and-see approach.

Fourth, has there been a similar drop in asthma-related school absences? According to the city health department, asthma is a leading cause of school absences. So, if child asthma hospitalization rates have been cut in half in many neighborhoods, school attendance should have increased somewhat to account for all of the now-healthy children.

The Fruits of Knowledge

Clearly, there is a level of awareness of, and service for, asthma that did not exist in 1995. In my son’s case, he was ultimately diagnosed with, and treated for, a soy allergy, and we put the inhaler away for good. Throughout the system, children, parents, teachers, nurses, doctors and other healthcare providers all are doing a better job at diagnosing, treating and managing the asthma (and non-asthmatic allergies) of our city’s children.

Since 1999, the health department’s Asthma Initiative has coordinated the NYC Asthma Partnership, a citywide coalition of more than 300 organizations and individuals. It manages an impressive array of educational and training programs for schools, daycare facilities, healthcare institutions and other key links in the asthma services chain. (Check out their Web site, which includes neighborhood-by-neighborhood data, summaries of available education and training programs and much more).

But I’m still wondering about the four questions posed above. Mostly, I’m trying to figure out whether asthma itself has been reduced, or whether it’s being moved out of the city’s emergency rooms. If you have thoughts on this, post a comment. Maybe we can all get to the bottom of this story.

( I am so stunned by the data—and the lack of coverage—that I decided to write about this asthma story, rather than the article about PlaNYC that I promised you last month. Look for that story in November.)

Rich Kassel is a senior attorney at the Natural Resources Defense Council (NRDC), where he focuses on urban air pollution and transportation issues. He also chairs the Tri-State Transportation Campaign, a regional transportation advocacy organization, and is on the boards of the New York League of Conservation Voters and Transportation Alternatives. In addition to his Gotham Gazette pieces, he blogs on a variety of environmental issues on the NRDC Switchboard at http://switchboard.nrdc.org/blogs/rkassel.

 

 

 

Grading the City's Public Hospitals


New York City is a world of infinite decisions: Japanese or Vietnamese, a ball game or the opera and the subway or a cab.

Some decisions, though, involve more serious matters. Selecting a hospital is one. But now New Yorkers trying to decide whether to go to Coney Island Hospital or Kings County Hospital Center have a little more information to guide them.

Last month on its Web site, the city’s Health and Hospitals Corporation voluntarily released infection and mortality rates for each of its 11 public hospitals. It was the first hospital system in the state to do so, said the corporation's chief executive officer and president, Alan D. Aviles.

The data, which is accessible here, compares the corporation's facilities with regional and national averages and allows New Yorkers to analyze and compare hospital against hospital.

Hailed by health care advocates for casting light on a secretive industry, the release of this data has shifted attention to the perception of public hospitals and their ability to provide quality care in all five boroughs. Although the corporation's acute care facilities score above state and national averages, a familiar discrepancy emerges within its own network: Hospitals in lower income areas tend to do worse than those in higher income areas.

The Information Trend

Although most of the information the corporation has posted on its Web site is regurgitated from either the state or federal hospital reporting system (which are also available online here federally and here on the state level), the corporation added specific mortality data on each hospital and statistics on infections acquired in hospitals. Since the corporation took this step last month, another New York hospital–North Shore Long Island Jewish Health System – has already followed its lead.

New York State began releasing hospital mortality data on coronary bypass surgery in the late 1980s. Then, the public information movement stalled. Advocates attributed this to an increasingly powerful health care industry and a reluctance to disseminate seemingly private information.

" If we back up 20 to 30 years, health care was a very private transaction between a patient and a physician," said former state legislator James R. Tallon, now the president of United Hospital Fund of New York, a health care policy organization. "In a sense it's sort of a movement to say we are going to make it more publicly available. We live in a world where information moves much more freely."

In 2005, the state legislature approved more rigorous reporting standards, which would result in the release of hospital report cards and hospital-related infection rates in 2009. Those regulations are currently being rolled out.

The Health and Hospitals Corporation's voluntary release of its data puts it a step ahead of the state statute.

The Corporation's Score

Overall, the corporation's hospitals have average mortality rates that are better than state, regional and federal averages.

However, its average mortality rate following heart attacks is slightly worse than the statewide figure – the corporation had 15.8 patients die within 30 days of a heart attack from July 2005 to June 2006, while the statewide average is 15.6. For heart failure, based on the same 30-day measure in the same time period, the corporation scored better than the statewide average -- 10.6 compared to 11.

Data on the death rates from heart failure and heart attacks were provided by the federal Centers for Medicare and Medicaid Services, which take into account only Medicare patients. Those patients, said Aviles, comprise just 15 percent of the corporation’s patient base.

When comparing the corporation's 11 hospitals, a familiar outcome is apparent: Facilities in the outer boroughs and in more impoverished neighborhoods have higher mortality rates than those in Manhattan.

" Quite frankly, we're talking about the hospitals in the outer boroughs and the health of the communities is often poorer," said Aviles. "There are more patients with low incomes, that are uninsured," he added.

For hospital wide mortality rates, the lowest ranking facilities – Coney Island Hospital in Brooklyn at 3.14 percent, Kings County Hospital Center in Brooklyn at 1.72 percent and Elmhurst Hospital Center in Queens at 1.64 percent – are all located in the outer boroughs.

The hospital wide mortality rates are not risk adjusted, Aviles said, and so do not take into account the types of patients or trauma seen at each location. Because the Coney Island center sees a disproportionate number of elderly nursing home patients and Elmhurst sees terminally ill patients needing hospice care, the figures might not accurately reflect the facility's quality. The hospitals with the lowest mortality rates, including North Central Bronx Hospital at .67 percent, followed by Manhattan-based Metropolitan Hospital Center at .68 and Queens Hospital Center at .96 percent, were not all in Manhattan either.

The corporation's acute care facilities are dispersed throughout the boroughs: Brooklyn has four hospitals, Manhattan has three and both the Bronx and Queens have two (Staten Island has one rehabilitation facility).

None of the three Manhattan facilities ever fell within the bottom quarter of the corporation's mortality lists, and one, Metropolitan Hospital Center, was always among the three hospitals with the lowest mortality rates based on hospital wide, heart failure and heart attack data. On the other hand, Jacobi Medical Center in the Bronx has one of the highest mortality rates for both heart attacks and heart failure.

Data on hospital-related infections had similar results. Patients in hospitals in the outer boroughs accumulated infections more frequently than those in Manhattan.

When comparing preventable, sometimes-fatal bloodstream infections affecting patients in intensive care units – otherwise known as central line infections – Kings County again sank to the bottom of the corporation's list with 11 per 1,000 CL days, which takes into account the number of days and amount of patients with a central line. A Manhattan hospital, Bellevue Hospital Center, topped the list with a rate of 1.7. Numerous hospitals in the outer boroughs went more than four months without having a central line infection.

The Health Care Gap

Because patients outside of Manhattan are more likely to be uninsured, said Aviles, they do not have the same access to preventative medicine. They may not have a primary physician or are recent immigrants. Also, the corporation's president added, many of the hospitals in the outer boroughs, like Jacobi Medical Center, Kings County and Elmhurst, serve as trauma centers – locations that would obviously see an influx of patients who are injured more severely.

The discrepancies in access to health care based on race and income have been documented previously. A report released last month by City Comptroller William Thompson showed residents of lower income neighborhoods are more likely to suffer from heart disease, diabetes and cancer than people in more affluent areas.

Although quality of care disparities by borough are evident in the corporation's data, many advocates said the public hospitals in poorer neighborhoods have come a long way since the 1990s.

Public Versus Private Care

The Giuliani administration’s lack of support for the city's public hospitals left the facilities without sufficient resources to provide proper care, said some advocates. And with that, they added, came the public perception that public hospitals were less reliable and safe than private ones.

The Health and Hospitals Corporation, however, has received renewed attention during Mayor Michael Bloomberg's tenure. With a $200 million boost to its operating budget in 2004, Bloomberg aimed at reinvigorating the public health industry. That effort has been seen in the hospital's greater ability to provide quality health care, said Aviles.

" We have a mayor that is very knowledgeable about health care," the corporation's president said. "We're just glad that we're getting to the point that we have data (that reflects) what the mayor is saying."

Even Aviles recognizes that many New Yorkers see public hospitals as riskier than private ones. That stereotype, he added, is outdated, thanks to Bloomberg.

The data helps point to the better quality of care at the corporation's facilities. Many of the intensive care units within the corporation have reduced central line bloodstream infections by 30 percent over the last two years, according to the corporation.

" There has sort of been over the years a public perception that public hospitals are not as good as private hospitals," said Arthur A. Levin, the director of the New York City based Center for Medical Consumers. "I'm sure that is the reason why HHC published this data. It makes them look really good."

The Data Debate

Because a large chunk of the data released by the corporation only measures Medicare patients and the overall mortality rates do not take into account a patient’s age or ailment, some advocates argue the data does not accurately measure quality of care.

Bruce Boissonnault, president and chief executive officer of Niagara Health Quality Coalition, which independently measures all the state's hospitals, said the corporation's move to release data is commendable, but medical consumers in New York State must keep in mind the source of information. Measuring whether a patient receives an aspirin when having a heart attack, does not necessarily mean that patient survives, he added. Context is everything.

"What you want to know is which hospital do I need to go to to walk out of the hospital alive, and where do I go to get a doctor that will follow up," said Boissonnault.

Boisssonault's group examines millions of anonymous patient records to score hospitals statewide. According to its measurements, most of the corporation's hospitals fall within the state average for mortality indicators based on inpatient conditions.

Since the state, let alone the country, are relatively new at collecting quality of care data, advocates said, no research methodology or data collection system is going to perfectly reflect a hospital's quality. "Because we're in the infancy of collecting data on (quality of care) measurements and reporting it, there are problems," said Levin. But, he added, "Do you wait for the perfect, or do you wait for the good enough?" 

Aging with AIDS


When Edward Shaw was diagnosed with the human immunodeficiency virus, or HIV, in August 1988, he thought it was a death sentence. But now, the burly, 66-year-old resident of the Upper West Side seems far removed from the nearly two-decade old diagnosis.

"I smile a lot," Shaw said with a chuckle on a recent afternoon.

Shaw is not alone. As antiretroviral drugs become increasingly successful at keeping people with HIV alive and healthy, the virus is steadily trickling into a once-unforeseen population - seniors.

HIV victim turned AIDS activist, Shaw, in partnership with several New York City-based nonprofit and advocacy organizations, has helped spearhead a city-funded campaign to educate this growing population on the dangers and prevalence of HIV and AIDS. That campaign is intended to put HIV prevention information in the hallways of senior centers and condoms in the pockets of elderly New Yorkers.

Treating a New Population

When HIV was first diagnosed in 1981 it was a disease that supposedly infected only gay men. In fact, AIDS went by another acronym - GRID or gay-related immune deficiency.

As information spread, so did the disease. From intravenous drugs users to heterosexual women and men of all races, it is now readily acknowledged that HIV and AIDS do not discriminate.

But a HIV diagnosis is also no longer judgment day for many individuals. Drug cocktails introduced in the mid to late 1990s - which may require a daily regimen of a dozen pills - have kept those diagnosed with HIV in the 1980s healthy for decades. And while people with the virus continue to grow older and remain sexually active, they may expose other older New Yorkers to the virus, said AIDS advocates.

According to the city's Department of Health and Mental Hygiene, nearly 100,000 individuals are living with HIV or AIDS in New York City. As of July 2006, more than 31 percent of them were over the age of 50 and 70 percent were over the age of 40.

New York City has long been a hub for populations infected with HIV – the city has the highest rate in the country – and the aging population here might foreshadow a national trend.

According to the Centers for Disease Control and Prevention, those over 50 account for 12.5 percent of the approximately million individuals living with AIDS in the United States. That same age bracket comprised an estimated 15 percent of the new cases of HIV from 33 states in 2005.

From 1991 to 1996, new AIDS cases in the over 50-population increased by 22 percent nationally, according to a report by the City Council's committees on health, aging and senior centers. During that same time period, new cases for those between 13 and 49 years old increased by 9 percent.

A report released by the New York City-based AIDS Community Research Initiative of America, said it is "probable" that the majority of people living with AIDS could reach 50 years old within the next decade. That could complicate HIV education, access to healthcare and how health care providers and city officials address, prevent and mange the virus.

Safe Sex for Seniors

Shaw was 47 years old when he learned he had contracted HIV. Because he is not gay and information on contracting HIV from intravenous drug use – which was how Shaw was infected – was not widespread, he figured this growing pandemic couldn't affect him.

"I had to reeducate myself about this thing that was ravaging my body," Shaw said of his diagnosis's aftermath. "Back in 1988, there was little if any information in the community, specifically to reach older adults. The little knowledge I had then was it affected gay white men, it affected homosexuals, and it affected folks from Africa. My not being any of those, I said, 'Well, I don't have anything to worry about.' Or so I thought."

That same indifference is seen now in senior populations. Older people do not realize they too can contract HIV, Shaw said.

Although seniors remain sexually active as they age, menopause and a lack of education make using condoms a rarity, advocates said. Even talking about sex is often taboo in senior centers and specialized geriatric medical offices.

"You have to get seniors to start comfortably talking about sex," said Bobbie Sackman, director of public policy at the Council of Senior Centers and Services. "This population has never been targeted for education. … Seniors have sex."

HIV status, one survey found, does not deter seniors from sexual activity. A survey of 914 New York City residents with HIV or AIDS over the age of 50 conducted by the AIDS Community Research Initiative of America found that half were sexually active and, of them, more than 30 percent had sex with individuals regardless of their HIV status.

Treating and Diagnosing the Elderly with HIV

While treating AIDS at any age is difficult, it can be more difficult for those growing old with HIV or contracting it in later years. Dr. Monica Sweeney, assistant commissioner of the Bureau of HIV/AIDS Prevention and Control at the Department of Health and Mental Hygiene, said that, as the body grows older, the kidneys become less likely to handle medication. Other HIV prescriptions can increase the risk of heart disease – a dangerous side effect for those over 50.

"Just becoming a senior makes all of your treatments more difficult because of the natural and biological effects of aging," said Sweeney.

According to ACRIA's report, little research has been conducted on the effects of HIV on other ailments, like cardiovascular disease or osteoporosis, typically associated with seniors. But what several studies have shown, according to the report, is that seniors have a vastly higher chance of living with HIV if they are treated with antiretroviral drugs. If untreated, older individuals are twice as likely to die from the virus than younger populations.

Many of the symptoms associated with HIV or AIDS are also associated with aging – such as weight loss, memory loss, fatigue and shortness of breath. As a result, some seniors wither away from AIDS undiagnosed, assuming their health problems are from aging. But in the meantime, they may still be having unprotected sex.

"You can see the way the virus is ravaging the bodies of the elderly, yet they are walking around with it not knowing," said Shaw. "And not realizing that that ache or that loss of appetite or that dementia is an AIDS symptom, not an aging symptom."

Elderly individuals diagnosed with HIV are also at risk of more than the usual physical ailments. Daniel Tietz, executive director of the AIDS Community Research Initiative of America, said seniors who have HIV or AIDS are twice as likely to live alone as other New Yorkers in the same age bracket. The loneliness that may accompany that statistic could increase the risk of suffering from the mental side effects of the virus.

Treating seniors like the rest of the "at risk" population is part of addressing the problem. Overall, Sweeney said, it is misguided to single out any constituency, color or ethnicity - everyone needs to get tested.

What the City is Doing

Following a joint hearing by the aging and health committees and the senior centers subcommittee of the City Council last year, Councilmember Maria del Carmen Arroyo and AIDS advocates established a working group to come up with a program aimed at seniors.

"Aging in it of itself is a challenge," said Arroyo. "Complicate that with HIV and AIDS and the health care provider and community organizations have a greater challenge to meet the needs."

With a $1 million budget appropriation, several New York City groups are drafting a training curriculum for senior service providers, including senior center employees and medical professionals, that will direct them on how to educate seniors about safe sex, AIDS and HIV. The funding will also go toward educational materials for seniors and intensified programs in the council districts where HIV and AIDS are most prevalent and seniors are most at risk.

The program is the first in the country, advocates said, and the first in the city to target seniors exclusively for HIV and AIDS education. Although the health department, officials said, has distributed literature and conducted prevention programs citywide, this program would address the hesitations and apprehension of the elderly to talk about sex - let alone safe sex.

By next year, advocates said, every council district would have held at least a training session for senior service providers.

In addition to the City Council initiative, the city's Department of Aging has also recently offered free HIV tests and distributed condoms at senior centers.

Getting Gray and Being OK

As medical breakthroughs occur and those with HIV continue to live longer, Shaw and advocates agree education and prevention will become increasingly important.

While he hopes for a vaccine in his lifetime, until then Shaw will continue to visit senior centers and churches to shed light on HIV and AIDS for seniors. With two decades down since his diagnosis, he has a lifetime of advocacy and education to go.

"Education, education, education," he said. "And as often as possible."

 



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