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Biomedical subjects

E F Mitchel

Publications and source records attributed to E F Mitchel.

At least 19 recordsLinked to original sources
PubMed2001

Use of healthcare resources among medically and surgically treated patients with gastroesophageal reflux disease: a population-based study.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medically or surgically. Direct evaluations of medical resource use are needed to better understand the relative costs of these alternatives. This study compared medical care use for a group of patients receiving surgical treatment for GERD with that for a comparable group of patients receiving medical management. STUDY DESIGN: We conducted a retrospective matched cohort study of Tennessee Medicaid (TennCare) patients with GERD undergoing surgical treatment in 1996 and a group of patients who received medical therapy during the same period. Administrative TennCare data provided computerized records that could be used to identify patients and measure healthcare use. There were 7,502 people who met all of the conditions for inclusion in the study, including at least two encounters with a diagnosis of GERD. One hundred thirty-five of these who underwent fundoplication constituted the surgically treated cohort. The 250 persons in the medically treated cohort were selected randomly from the remaining nonsurgical patients and matched to the surgical cohort by age, gender, race, managed care organization, and acid suppression drug use in the baseline year. The principal outcome of interest was total use of medical resources, including prescription medication. RESULTS: The surgical and medical cohorts did not differ significantly by demographic characteristics or by baseline use of pharmaceuticals. During the baseline year the surgically treated patients were prescribed 302 (95% CI: 270-334) days ofGERD treatment and the matched medical patients were prescribed 292 (95% CI: 267-317) days of GERD treatment. Surgically treated patients used more GERD-related outpatient resources (physician visits and diagnostic testing) in the baseline year, particularly in the 3 months before operation, when they had a mean of more than four outpatient encounter-days. In the followup year, use of GERD-related pharmaceuticals decreased markedly in the surgical cohort. These patients were prescribed an average of 123 days (95% CI: 94-153) of therapy, which was only 36% of that for medical patients (339 days [95% CI: 308-370]). More than 29% of surgical patients were prescribed no GERD-related drugs in the followup year compared with 6% of the medically treated group. The mean number of inpatient days for the fundoplication procedure was 3.2 (95% CI: 2.7-3.6), with a range of 0 to 13 days. There were no differences between the two groups in other healthcare use. CONCLUSIONS: Our results show that in a 1-year period of followup, surgical treatment of severe gastroesophageal reflux disease led to a 64% postsurgical reduction in GERD medication use, with no increase in use of other medical services.

Adolescent↗
PubMed2000

The effect of influenza on hospitalizations, outpatient visits, and courses of antibiotics in children.

BACKGROUND: Despite high annual rates of influenza in children, influenza vaccines are given to children infrequently. We measured the disease burden of influenza in a large cohort of healthy children in the Tennessee Medicaid program who were younger than 15 years of age. METHODS: We determined the rates of hospitalization for acute cardiopulmonary conditions, outpatient visits, and courses of antibiotics over a period of 19 consecutive years. Using the differences in the rates of these events when influenzavirus was circulating and the rates from November through April when there was no influenza in the community, we calculated morbidity attributable to influenza. There was a total of 2,035,143 person-years of observation. RESULTS: During periods when influenzavirus was circulating, the average number of hospitalizations for cardiopulmonary conditions in excess of the expected number was 104 per 10,000 children per year for children younger than 6 months of age, 50 per 10,000 per year for those 6 months to less than 12 months, 19 per 10,000 per year for those 1 year to less than 3 years, 9 per 10,000 per year for those 3 years to less than 5 years, and 4 per 10,000 per year for those 5 years to less than 15 years. For every 100 children, an annual average of 6 to 15 outpatient visits and 3 to 9 courses of antibiotics were attributable to influenza. In winter, 10 to 30 percent of the excess number of courses of antibiotics occurred during periods when influenzavirus was circulating. CONCLUSIONS: Healthy children younger than one year of age are hospitalized for illness attributable to influenza at rates similar to those for adults at high risk for influenza. The rate of hospitalization decreases markedly with age. Influenza accounts for a substantial number of outpatient visits and courses of antibiotics in children of all ages.

Acute Disease↗
PubMed2000

The burden of influenza illness in children with asthma and other chronic medical conditions.

OBJECTIVE: Although influenza immunization is recommended for children with high-risk medical conditions, the majority of such children do not receive influenza vaccine. This study was designed to measure the burden of influenza among children with asthma and other chronic medical conditions. STUDY DESIGN: We performed a retrospective cohort study of children younger than 15 years with medically treated asthma or other chronic medical conditions enrolled in the Tennessee Medicaid program from 1973 to 1993. We determined rates of hospitalization for acute cardiopulmonary disease, outpatient visits, and antibiotic courses throughout the year. Annual differences between event rates when influenza virus was circulating and event rates during winter months when there was no influenza in the community were used to calculate influenza-attributable morbidity. RESULTS: Influenza accounted for an average of 19, 8, and 2 excess hospitalizations for cardiopulmonary disease yearly per 1000 high-risk children aged <1 year, 1 to <3 years, and 3 to <15 years, respectively. For every 1000 children, an estimated 120 to 200 outpatient visits and 65 to 140 antibiotic courses were attributable to influenza annually. CONCLUSIONS: Children younger than 15 years with asthma and other chronic medical conditions experience substantial morbidity requiring inpatient and outpatient care during influenza season. More effective targeting of this population for annual influenza immunization is warranted.

Adolescent↗
PubMed2000

Rates of hospitalization for respiratory syncytial virus infection among children in medicaid.

OBJECTIVE: To determine rates of hospitalization associated with respiratory syncytial virus (RSV) infection among children with and without specific medical conditions. STUDY DESIGN: Retrospective cohort study of all children <3 years old enrolled in the Tennessee Medicaid program from July 1989 through June 1993 (248,652 child-years). RESULTS: During the first year of life, the estimated number of RSV hospitalizations per 1000 children was 388 for those with bronchopulmonary dysplasia, 92 for those with congenital heart disease, 70 for children born at < or = 28 weeks' gestation, 66 for those born at 29 to <33 weeks, 57 for those born at 33 to <36 weeks, and 30 for children born at term with no underlying medical condition. In the second year of life, children with bronchopulmonary dysplasia had an estimated 73 RSV hospitalizations per 1000 children, whereas those with congenital heart disease had 18 and those with prematurity 16 per 1000. Overall, 53% of RSV hospitalizations occurred in healthy children born at term. CONCLUSIONS: Children with bronchopulmonary dysplasia have high rates of RSV hospitalization until 24 months of age. In contrast, after the first year of life, children with congenital heart disease or prematurity have rates no higher than that of children at low risk who are <12 months old.

Bronchopulmonary Dysplasia↗
PubMed2000

Underutilization of controller and rescue medications among older adults with asthma requiring hospital care.

BACKGROUND: Asthma causes serious morbidity in older people, but pharmacologic therapy in older people with asthma has never been studied, at least in part because of the difficulty of defining asthma in this population. OBJECTIVE: To determine if older persons enrolled in Medicaid and hospitalized with an exacerbation of asthma receive appropriate outpatient asthma care. DESIGN: Descriptive pharmacoepidemiology of a group of older adults with asthma. SETTING: The Tennessee Medicaid Program. PARTICIPANTS: Persons aged 65 and older, enrolled in the Tennessee Medicaid program, identified through Medicaid's computerized database as having a hospital care visit for asthma in 1992 and who had their diagnosis confirmed by chart review. MEASUREMENT: Medication utilization. RESULTS: The source population included 93,686 persons aged 65 or older enrolled in the Tennessee Medicaid program. The group meeting study criteria included 512 patients with chronic asthma who had a hospital care visit for an asthma exacerbation. Eighty-one percent of these 512 persons with an asthma hospitalization confirmed by chart review were classified as having moderate to severe or potentially fatal asthma. These patients had had a median of 15 outpatient visits in the previous year, and more than half of them had an outpatient visit in the 14 days before their hospitalization. However, among those with moderate to severe or near fatal asthma only 25% filled prescriptions for inhaled corticosteroids, whereas 52% were taking theophylline, the most commonly prescribed asthma medication in this group. There was also high use of antibiotics (29%) and low use of rescue corticosteroids (5%) before the hospital care visit, despite frequent medical encounters. CONCLUSIONS: Despite widespread promulgation of the National Asthma Education Prevention Program guidelines, our study suggests that providers caring for indigent older subjects with moderate to severe or potentially fatal asthma were not following these guidelines. There was significant underutilization of inhaled anti-inflammatory agents, beta-agonists, and rescue corticosteroids in this population despite frequent outpatient medical care visits.

Administration, Inhalation↗
PubMed1999

Early childhood mortality from community-acquired infections.

In this study, the authors identified maternal and child characteristics that were independent predictors of death from infectious diseases acquired in the community and determined if these factors could be used to identify groups of children with excess risk of mortality from infection. A historical cohort study was conducted of children less than 5 years of age between 1985 and 1994 (the study period), who were born in Tennessee, and had complete information on their birth certificates. The primary outcome was death from infection identified from death certificates and confirmed through medical record review. Among the 1,014,976 children less than 5 years of age, who contributed 3,351,568 child-years of follow-up, there were 247 deaths from infections (7.4 deaths from infections per 100,000 child-years). Respiratory infections accounted for approximately one half of the deaths. Children having three or more older siblings or birth weight of less than 1,500 g had a 3-fold and 10-fold increased risk of death from infection, respectively, while children with both characteristics had a nearly 20-fold increased risk that persisted beyond the first year of life. Interventions should be focused on prevention of these infections in vulnerable children. At-risk children should be targeted for careful follow-up and early hospitalization when signs of infection develop.

Child, Preschool↗
PubMed1999

Influenza-associated morbidity and mortality in young and middle-aged women.

CONTEXT: Data are limited on rates of influenza-associated hospitalizations and deaths among adults younger than 65 years. OBJECTIVE: To quantify serious morbidity and mortality from influenza for women younger than 65 years with and without certain chronic medical conditions, including human immunodeficiency virus infection. DESIGN: Retrospective cohort study. SETTING AND POPULATION: Women aged 15 to 64 years enrolled in the Tennessee Medicaid program from 1974 to 1993. MAIN OUTCOME MEASURE: All hospitalizations for and deaths from pneumonia, influenza, and other selected acute cardiopulmonary conditions for women with and without selected chronic medical conditions during 19 consecutive years. Influenza-attributable risk was calculated by subtracting event rates during peri-influenza season (November through April of each year when influenza virus was not circulating) from adjusted rates during influenza season (November through April when influenza virus was circulating). RESULTS: During the 19 years of the study, we identified 53607 acute cardiopulmonary hospitalizations and deaths. Rates of such events were consistently higher during influenza seasons than peri-influenza seasons. Among high-risk women, the estimated annual excess was 23 hospitalizations and deaths per 10000 women aged 15 to 44 years and 58 such events per 10000 women aged 45 to 64 years. The estimated annual excess mortality due to influenza was 2 deaths per 10000 high-risk women for both age groups combined. Among women with no identified high-risk conditions, estimated annual excess hospitalizations and deaths were 4 and 6 per 10000 women aged 15 to 44 and 45 to 64 years, respectively. CONCLUSIONS: Women younger than 65 years with certain chronic medical conditions experience substantial morbidity and mortality from acute cardiopulmonary events during influenza season. More effective targeting of these populations for annual influenza immunization is warranted.

Adolescent↗
PubMed1999

Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions.

OBJECTIVE: To determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991. METHODS: This retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery. RESULTS: Among 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1-3 prior births. CONCLUSION: Predictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.

Adolescent↗
PubMed1999

Comparison of perinatal outcomes among TennCare managed care organizations.

OBJECTIVE: To compare perinatal outcomes among the managed care organizations (MCOs) providing care to beneficiaries enrolled in TennCare, Tennessee's capitated Medicaid managed care program. DESIGN: Retrospective cohort analysis. SUBJECTS: Infants born in Tennessee during 1995 to women enrolled in TennCare. PRIMARY OUTCOME MEASURES: Prenatal care use, birth weight (BW), death in the first 60 days of life, and delivery of extremely low BW (<1000 g) infants in hospitals without level 3 neonatal intensive care units. RESULTS: During 1995, 34 402 infants were born to mothers enrolled in TennCare. The MCOs differed widely in the demographic characteristics of their enrollees. In addition, there were small differences in prenatal care utilization, but no differences in BW outcomes among the MCOs. In multivariate analysis, however, infants born to women enrolled in 1 MCO were 2.8 times more likely to die in the first 60 days of life than were infants born to women enrolled in the largest MCO (OR: 2.81; 95% CI: 1.31-6.03). Women enrolled in this same MCO seemed to have a higher proportion of extremely low BW (<1000 g) infants delivering in a hospital lacking a level 3 neonatal intensive care unit (38% vs 20% in the largest MCO). CONCLUSION: The differences among MCOs in early infant death and in the delivery of high-risk infants in hospitals lacking appropriate neonatal facilities suggest that monitoring of care delivery to vulnerable children should include assessment of appropriate use of specialized services.

Adult↗
PubMed1998

Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women.

This study sought to quantify influenza-related serious morbidity in pregnant women, as measured by hospitalizations for or death from selected acute cardiopulmonary conditions during predefined influenza seasons. The study population included women aged 15-44 years who were enrolled in the Tennessee Medicaid program for at least 180 days between 1974 and 1993. In a nested case-control study, 4,369 women with a first study event during influenza season were compared with 21,845 population controls. The odds ratios associated with study events increased from 1.44 (95% confidence interval (CI) 0.97-2.15) for women at 14-20 weeks' gestation to 4.67 (95% CI 3.42-6.39) for those at 37-42 weeks in comparison with postpartum women. A retrospective cohort analysis, which controlled for risk factors identified in the case-control study, identified 22,824 study events during 1,393,166 women-years of follow-up. Women in their third trimester without other identified risk factors for influenza morbidity had an event rate of 21.7 per 10,000 women-months during influenza season. Approximately half of this morbidity, 10.5 (95% CI 6.7-14.3) events per 10,000 women-months, was attributable to influenza. Influenza-attributable risks in comparable nonpregnant and postpartum women were 1.91 (95% CI 1.51-2.31) and 1.16 (95% CI -0.09 to 2.42) per 10,000 women-months, respectively. The data suggest that, out of every 10,000 women in their third trimester without other identified risk factors who experience an average influenza season of 2.5 months, 25 will be hospitalized with influenza-related morbidity.

Adolescent↗
PubMed1998

Prenatal exposure to metronidazole and risk of childhood cancer: a retrospective cohort study of children younger than 5 years.

BACKGROUND: To evaluate the role of in utero exposure to metronidazole (a carcinogen in some animal models) and the risk of subsequent cancer, the authors conducted a retrospective cohort study of childhood cancer. METHODS: The cohort included 328,846 children younger than 5 years born to women enrolled in Tennessee Medicaid at any time between the last menstrual period (LMP) and the date of delivery. The cohort was identified by linking files of Tennessee Medicaid mothers ages 15-44 years and children and the children's birth and death certificates for the period January 1, 1975 through December 31, 1992. Exposure data were obtained from Medicaid pharmacy records and exposure was defined as filling a metronidazole prescription that had at least a day's supply between the 30 days prior to the LMP and the date of delivery. Study cases were cohort children diagnosed with a first primary cancer before age 5 years, identified by linking the cohort with a statewide childhood cancer database for the study period. RESULTS: Cohort members contributed 1,172,696 person-years of follow-up for analysis, with children exposed (8.1%) and not exposed (91.9%) in utero to metronidazole contributing 79,716 and 1,092,980 person-years, respectively. Of 952 children younger than 5 years in the statewide cancer database, 175 met study eligibility criteria. Of these, 42 had leukemia, 30 had central nervous system (CNS) tumors, 28 had neuroblastoma, and 75 had other cancers. Using Poisson regression modeling, children exposed to metronidazole in utero had no significant increase in adjusted relative risk (RR) for all cancers (RR: 0.81; 95% confidence interval [95% CI], 0.41-1.59), leukemia (no exposed case), CNS tumors (RR: 1.23; 95% CI, 0.29-5.21), neuroblastomas (RR: 2.60; 95% CI, 0.89-7.59), and other cancers (RR: 0.57; 95% CI, 0.18-1.82). CONCLUSIONS: The authors conclude that although there was no increase in risk for all cancers associated with in utero exposure to metronidazole, the observed increased risk for neuroblastomas, although not significant, requires further evaluation.

Adolescent↗
PubMed1998

Perinatal outcomes following implementation of TennCare.

CONTEXT: The abrupt initiation of capitated Medicaid care in Tennessee (TennCare) in 1994 prompted many questions about changes in quality of care. OBJECTIVE: To evaluate the effect on perinatal outcomes of the transition to TennCare in 1994. DESIGN: Before and after retrospective cohort analysis. SETTING AND POPULATION: Births to women residing in Tennessee between 1990 and 1995 with complete demographic information on birth certificates, with a focus on women enrolled in Medicaid giving birth in 1993 (before TennCare) and 1995 (after TennCare). OUTCOME MEASURES: Late prenatal care (after the fourth month of pregnancy) or inadequate prenatal visits, low and very low birth weight, and death in the first 60 days of life. RESULTS: Tennessee residents had 72014 study births in 1993 and 72278 in 1995, of which 37543 (52.1%) and 35707 (49.4%) were to women enrolled in Medicaid at delivery. For these Medicaid births, there were no changes after TennCare in the proportions with late prenatal care (16.2% in 1993 vs 15.8% in 1995), inadequate prenatal visits (5.9% vs 5.6%), low birth weight (9.4% vs 9.0%), very low birth weight (1.6% vs 1.5%), and death in the first 60 days (0.6% both years). These findings were unchanged in multivariate analysis, in analysis of high-risk subgroups, and in analysis of women with demographics characteristic of Medicaid women. CONCLUSION: Study perinatal outcomes did not change among Medicaid births following the transition to TennCare.

Birth Weight↗
PubMed1998

Predictors of mortality from fires in young children.

BACKGROUND: In the United States in 1994, fires claimed 3.75 lives per 100 000 child years and accounted for 17.3% of all injury deaths in children <5 years of age. OBJECTIVES: To conduct a historical cohort study that uses maternal demographic characteristics to identify young children at high risk of fire-related deaths, thus defining appropriate targets for prevention programs. METHODS: The cohort consisted of children born to mothers who resided in the state of Tennessee between 1980 and 1995. Information was obtained by linking birth certificates, 1990 census data, and death certificates. Children were eligible for the study if they were <5 years of age at any time within the study period and if key study variables were present (99.2% of births). Birth certificates provided information on maternal characteristics including age, race, education, previous live births, use of prenatal care, and residence (in standard metropolitan statistical area). Child characteristics included gender, gestational age, and birth type (singleton/multiple gestation). Neighborhood income was estimated by linking the mother's address at the time of birth to the 1990 census (block group mean per capita income). The study outcome was a fire resulting in at least one fatality (fatal fire event) during the study period, identified from death certificates (coded E880 through E889 in the International Classification of Diseases, 9th rev). We calculated the fatal fire event rate corresponding to each stratum of maternal/child characteristics. We assessed the independent association between each characteristic and the risk of a fatal fire event from a Poisson regression multivariate analysis. RESULTS: During the study period, 1 428 694 children contributed 5 415 213 child years to the cohort: there were 270 deaths from fire (4.99 deaths per 100 000 child years) and 231 fatal fire events. In the multivariate analysis, factors associated with greater than a threefold increase in fatal fire events included maternal education, age, and number of other children. Compared with children whose mothers had a college education, children whose mothers had less than a high school education had 19.4 times (95% confidence interval [CI], 2.6-142.4) an increased risk of a fatal fire event. Children whose mothers had more than two other children had 6.1 times (95% CI, 3.8-9.8) an increased risk of a fatal fire event compared with children whose mothers had no other children. Children of mothers <20 years of age had 3.9 times (95% CI, 2.2-7.1) increased risk of a fatal fire event compared with children whose mothers were >/=30 years old. Although both maternal neighborhood income and race were associated strongly with increased rates of fatal fire events in the univariate analysis, this association did not persist in the multivariate analysis. Other factors that were associated with increased risk of fatal fire events in the multivariate analysis were male gender and having a mother who was unmarried or who had delayed prenatal care. The three factors associated most strongly with fire mortality were combined to create a risk score based on maternal education (>/=16 years, 0 points; 13 to 15 years, 1 point; 12 years, 2 points; <12 years, 3 points); age (>/=30 years, 0 points; 25 to 29 years, 1 point; 20 to 24 years, 2 points; <20 years, 3 points); and number of other children (none, 0 points; one, 1 point; two, 2 points; three or more, 3 points). The lowest-risk group (score <3) included 19% of the population and had 0.19 fatal fire events per 100 000 child years. In contrast, highest-risk children (score >7) comprised 1.5% of the population and had 28.6 fatal fire events per 100 000 child years, 150 times higher than low-risk children. Children with risk scores >5 contributed 26% of child years but experienced 68% of all fatal fire events. If the fatal fire event rate for all children had been equal to that of the low-risk group (risk score <3), then 95% of deaths from

Burns↗
PubMed1997

Persistently increased injury mortality rates in high-risk young children.

OBJECTIVE: To study trends in injury mortality for low- and high-risk young children. DESIGN AND METHODS: For Tennessee children 0 to 4 years of age, we used birth certificates to obtain data on maternal education, age, and parity; these risk factors were used to classify children into low- and high-risk groups. The outcome was death from injury, as determined from linked death certificates. Between 1978 and 1995, injury mortality rates were calculated for six 3-year periods for low- and high-risk children. RESULTS: There were 1.5 million children 0 to 4 years of age who contributed 4.9 million child-years. The high-risk group contributed 28% of all child-years. There were 673 injury deaths in the high-risk group, 48.9 deaths per 100,000 child-years, and 586 deaths in the low-risk group, 16.8 deaths per 100,000 child-years. The injury mortality rate for low-risk children decreased from 20.7 to 15.7 per 100,000 child-years between the 1978-1980 and 1981-1983 periods; thereafter it remained relatively stable. For high-risk children, the injury mortality rate decreased from 50.9 to 43.5 per 100,000 between the 1978-1980 and 1981-1983 periods, remained mostly unchanged through 1992, and then increased sharply in the 1993-1995 period to 64.1 per 100,000 child-years. The disparity between high- and low-risk children widened from 29.3 (95% confidence interval, 25.1-33.5) excess deaths per 100,000 for 1978 through 1991 to 46.9 (95% confidence interval, 35.9-57.9) in 1993 through 1995. CONCLUSIONS: In Tennessee, maternal education, age, and parity consistently identified a population of children at increased risk of injury mortality. For these high-risk children, there has been no substantial reduction in injury mortality in high-risk young children during the last 18 years.

Age Factors↗
PubMed1997

Predictors of injury mortality in early childhood.

OBJECTIVE: To study the association between maternal/infant characteristics and mortality from injury for children 0 through 4 years of age. DESIGN: Historical cohort. SETTING: State of Tennessee. PARTICIPANTS: Children 0 through 4 years of age at any time between January 1, 1985 and December 31, 1994. We linked birth certificates and US census data to obtain information on maternal age, race, education, neighborhood income, parity, use of prenatal care, residence location, infant's gender, and gestational age. MAIN OUTCOME MEASURES: The outcome was death from injury, as determined from linked death certificates. The incidence density rates for each stratum (defined by maternal/child characteristics) were calculated by dividing the number of injury deaths by child years in the stratum. We used multivariate analysis to assess the independent contribution of each characteristic to risk of injury death. RESULTS: There were 1 035 504 children 0 through 4 years of age who contributed 3 414 436 child years. There were 803 deaths from injury, ie, 23.5 deaths per 100 000 child years. In the multivariate analysis, children had at least a 50% increased risk of injury mortality if they were born to a mother who had less than a high school education (relative risk [RR] = 2.88; 95% confidence interval [CI]: 1.92-4.34) compared with a college education, was <20 years of age (RR = 2.42; 95% CI: 1.76-3.31) compared with >30 years, or had >2 other children (RR = 2.97; 95% CI: 2.29-3.85) compared with no other children. Neither race nor income was significantly associated with childhood injury mortality in the multivariate analysis. Classification of children by maternal education, age, and parity defined a pronounced risk gradient in which high-risk children had an injury mortality rate >15 times that of low-risk children. The steep risk gradient was present for both infants (24-fold increase for high-risk children) and children 1 through 4 years of age (13-fold increase for high-risk children). If the injury mortality rate for all children were equal to that of the low-risk group, 614/803 (76.3%) of injury deaths would not have occurred. CONCLUSIONS: For young children, maternal education, age, and parity are strongly and independently associated with injury mortality. These factors define a steep gradient of risk, suggesting that many injury deaths could be prevented.

Birth Certificates↗
PubMed1996

Improved outcomes for very low birth weight infants associated with the use of combined maternal corticosteroids and tocolytics.

OBJECTIVE: To determine the effects of maternal antenatal treatment with tocolytics, corticosteroids and the use of combined tocolytics and corticosteroids on the morbidity and mortality of very low birth weight infants. STUDY DESIGN: This retrospective study was conducted on all infants born in Tennessee in 1989 and 1990 who weighed < 1,500 g at birth and had no serious malformations. Registered nurses traveled to the delivery hospitals of all study subjects and abstracted information using a structured data collection form. Mortality was ascertained through the computerized linkage of birth and death certificates. Multiple logistic regression analysis was used to control for covariates. RESULTS: As compared to infants whose mothers received no treatment, infants whose mothers received both corticosteroids and tocolysis had a reduced risk of infant (odds ratio 0.38, 95% confidence interval 0.25-0.58) and neonatal mortality (OR 0.32, CI 0.19-0.51) as well as a reduced risk of seizures (OR 0.46, CI 0.23-0.93). Restricting the analysis of infants at 24-28 weeks' gestation and < 1,000 g at birth revealed similar findings regarding mortality. CONCLUSION: The use of combined corticosteroids with tocolytics was associated with better neonatal outcomes than the use of corticosteroids alone, tocolytics alone or no treatment.

Adrenal Cortex Hormones↗
PubMed1994

Presumptive eligibility for pregnant Medicaid enrollees: its effects on prenatal care and perinatal outcome.

OBJECTIVES: "Presumptive eligibility" permits pregnant prospective Medicaid enrollees to obtain services during the application period. The purpose of this study was to assess the effects of presumptive eligibility on the receipt of prenatal care and the occurrence of low-birthweight births and neonatal, perinatal, and infant mortality. METHODS: Outcome rates for pregnant women who enrolled in Tennessee Medicaid in the 6-month period before presumptive eligibility was enacted were compared with those obtained for pregnant women who enrolled in the 6-month period after presumptive eligibility had been in effect for 5 months. RESULTS: Women in the "after" group were 40% more likely to enroll and 30% more likely to obtain prenatal care in the first trimester. They were 300% more likely to fill a prescription for prenatal vitamins in the first trimester and 16% more likely to have begun prenatal care before the third trimester. However, they were similar to those enrolling in the "before" time period in terms of the occurrence of adverse perinatal outcomes. CONCLUSIONS: When barriers to prenatal care, including bureaucratic ones, are removed, low-income women will seek care earlier and more frequently.

Adolescent↗