Characterizing environmental asthma triggers and healthcare use patterns in Puerto Rico

Abstract

Objective: Asthma carries a high burden of disease for residents of Puerto Rico. We conducted this study to better understand asthma-related healthcare use and to examine potential asthma triggers.

Methods: We characterized asthma-related healthcare use in 2013 by demographics, region, and date using outpatient, hospital, and emergency department (ED) insurance claims with a primary diagnostic ICD-9-CM code of 493.XX. We examined environmental asthma triggers, including outdoor allergens (i.e., mold and pollen), particulate pollution, and influenza-like illness. Analyses included descriptive statistics and Poisson time-series regression.

Results: During 2013, there were 550,655 medical asthma claims reported to the Puerto Rico Healthcare Utilization database, representing 148 asthma claims/1,000 persons; 71% of asthma claims were outpatient visits, 19% were hospitalizations, and 10% were ED visits. Females (63%), children aged ≤9 years (77% among children), and adults aged ≥45 years (80% among adults) had the majority of asthma claims. Among health regions, Caguas had the highest asthma claim-rate at 142/1,000 persons (overall health region claim-rate = 108). Environmental exposures varied across the year and demonstrated seasonal patterns. Metro health region regression models showed positive associations between increases in mold and particulate matter <10 microns in diameter (PM₁₀) and outpatient asthma claims.

Conclusions: This study provides information about patterns of asthma-related healthcare use across Puerto Rico. Increases in mold and PM₁₀ were associated with increases in asthma claims. Targeting educational interventions on exposure awareness and reduction techniques, especially to persons with higher asthma-related healthcare use, can support asthma control activities in public health and clinical settings.

Keywords:

• Epidemiology
• management/ control
• prevention

Acknowledgements

The authors appreciate the support, contributions, and expertise of Drs. Ginger Chew and Fuyuen Yip in initiating this project and facilitating key collaborations. We thank the Epidemic Intelligence Service Program for facilitating training opportunities contributing to the development of this project. Special thanks to Mr. John Adames and Ms. Myribel Santiago at Puerto Rico Department of Health, Dr. Jeremy Sarnat at Emory University, and Drs. Wences Arvelo, Paul Garbe, Joy Hsu, Hatice Zahran, and Ms. Candi Cloud at the Centers of Disease Control and Prevention (CDC) for providing their insights, expertise, and support to this investigation. Many thanks to Mr. David Sánchez at the National Weather Service in San Juan, PR for contributing relative humidity and temperature data. We thank Mr. Randall Young and Ms. Laura Wright of the Geospatial Research, Analysis and Services Program (GRASP) at CDC for their guidance and contributions to geospatial data and resources. Additionally, we appreciate the insights of the Puerto Rico Environmental Quality Board regarding particulate matter and dust storms. The findings and conclusions in this report are those of the authors and do not necessarily represent the official positions of the Centers for Disease Control and Prevention, the National Institutes of Health, or the American Academy of Allergy, Asthma & Immunology.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Funding

The image capture equipment of the San Juan, AAAAI Station is supported in part by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NIH) under award number U54MD007600 and the Puerto Rico Clinical and Translational Research Consortium under NIH award No. 2U54MD007587-04.