The parallel movement of discharge rates apparent in Figure 3 would seem to indicate that in addition to individual and microenvironmental determinants of acute, severe asthmatic exacerbations, there are also global ones, or at least intercontinental ones, as well. The 25 percent decline in discharge rates observed among young white subjects could represent a cohort effect, in that these individuals are all recent accessions compared to the older groups, many of whom were recruited in the late 1970s and early 1980s, when the army experienced severe recruiting difficulties and, consequently, had lower entry standards than those established more recently. Overall poorer health may be a concomitant feature of lower standards, which would be reflected in hospital discharge rates for older soldiers. There is some visible decline in rates in young black subjects as well, but it is smaller in magnitude and less clearly consistent. asthma inhaler

All demographic groups at both locations exhibit some improvement in the last half of the study period, compared to the first half, except for older black subjects, who are worse off in later years, particularly in Europe. This is not inconsistent with data from the NHDS reported by Evans et al for the immediately preceding five years. In these data, discharge rates for nonwhite subjects increased by 38 percent from 1979 to 1983, while those for white subjects increased by 25 percent. In fact, the rates observed herein for black subjects in CONUS in 1988 are similar in absolute magnitude to those reported for 1983 in NHDS data cited previously. On the other hand, rates for white subjects are better than the national average for those in CONUS and worse, to nearly the same extent, in Europe.



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