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Biomedical subjects

K M McConnochie

Publications and source records attributed to K M McConnochie.

At least 19 recordsLinked to original sources
PubMed1999

How commonly are children hospitalized for asthma eligible for care in alternative settings?

OBJECTIVE: To estimate the proportion of children hospitalized for acute asthma exacerbation who might be cared for successfully in alternative settings such as short-stay units or in-home nursing. DESIGN: Descriptive study based on analysis of hospital discharge files and on retrospective medical record review of a random sample of asthma hospitalizations. METHODS: The 2028 asthma hospitalizations between 1991 and 1995 for children (aged <19 years) dwelling in Rochester, NY, were studied. Measures included the duration of frequent administration of nebulized medication (2 or more times in a 4-hour period), worst oxygen saturation levels, deterioration, and hospital length of stay. Oxygen saturation values and nebulized medication frequency were determined by hospital record review on a random sample of 443 asthma episodes. Length of stay was available for all admissions. RESULTS: Worst oxygen saturation following hospital admission was 95% or greater, 90% to 94%, and less than 90% for 21.3%, 51.6%, and 27.1% of episodes, respectively. Children received frequent nebulized medication treatments for a mean of 2.0 nursing shifts (8 hours per shift), although they remained hospitalized, on average, for 4.3 nursing shifts longer. Deterioration to a critical level of severity was uncommon. Among children initially admitted to the regular pediatric inpatient unit, only 0.7% subsequently deteriorated to the point that they were transferred to the critical care unit. CONCLUSION: More than 70% of asthma hospitalizations in this community could be cared for in alternative settings with supplemental oxygen, nebulized medication treatments, and close nursing observation provided, in most cases, for 2 nursing shifts.

Adolescent↗
PubMed1999

Socioeconomic variation in asthma hospitalization: excess utilization or greater need?

OBJECTIVE: To assess the hypothesis that higher incidence of severe acute asthma exacerbation, not lower severity threshold for admission, explains the difference between the asthma hospitalization rates of inner-city and suburban children. METHODS: All 2028 asthma hospitalizations between 1991 and 1995 for children (aged >1 month and <19 years) dwelling in Rochester, New York, were analyzed. ZIP codes defined residences as inner-city, other urban, or suburban. Based principally on the worst oxygen saturation (SaO2) during the first 24 hours of hospitalization, severity was examined by hospital record review (n = 443) of random samples of inner-city, other urban, and suburban asthma admissions. RESULTS: Large inner-city/suburban differences were noted in many sociodemographic attributes, and there was also a distinct, stepwise gradient in risk factors in moving from the suburbs to other urban areas and to the inner city. Racial and economic segregation was particularly striking. Black individuals accounted for 62% of inner-city births versus <3% in the suburbs. Medicaid covered 65% of inner-city births, whereas Medicaid covered only 6% of suburban births. The overall asthma hospitalization rate was 2.04 admissions/1000 child-years. Children <24 months old, those most commonly hospitalized for asthma, were fourfold more likely to be hospitalized (OR: 3.97, 95% CI: 3. 44-4.57) than children between the ages of 13 and 18 years. The hospitalization rate of asthma in boys was almost twice the rate of asthma in girls. The greatest gender difference was observed among children who were <24 months old. For these children, the rate for boys was 6.10/1000 child-years compared with 2.65/1000 child-years for girls (OR: 2.31, 95% CI: 1.95-3.03). This gender difference diminished gradually in older age groups to the extent that there was no difference among girls and boys between the ages of 13 and 18 years (males, 1.12/1000 child-years vs females, 1.09/1000 child-years). Based on worst SaO2 values, mild (worst SaO2 >/=95%), moderate (90%-94%), and severe (<90%) admissions constituted 10.3%, 41.9%, and 47.7% of all hospitalizations, respectively. Although rates within the community followed a distinct geographic pattern of suburban (1.05/1000 child-years) < other urban (2.99/1000 child-years) < inner-city (5.21/1000 child-years), the proportions of admissions with low severity did not vary among areas. Likewise, the proportions of admissions that were severe (SaO2 <90%) were not significantly different (44.8, 45.7, and 52.1% for suburban, other urban, and inner-city areas, respectively). The distributions of asthma severity, measured by the duration of frequent nebulized bronchodilator treatments and the length of hospital stay, were also similar among children from different socioeconomic areas. CONCLUSION: The marked socioeconomic and racial disparity in Rochester's asthma hospitalization rates is largely attributable to higher incidence of severe acute asthma exacerbations among inner-city children; it signals greater need, not excess utilization. Both adverse environmental conditions and lower quality primary care might explain the higher incidence. Interventions directed at the environment offer the possibility of primary prevention, whereas primary care directed at asthma is focused on secondary prevention, principally on improved medication use. Higher hospitalization rates cannot be assumed to identify opportunities for cost reduction. The extent to which our observations about asthma hold true under other conditions and in other communities warrants systematic attention. Knowledge of when higher rates signal excess utilization and when, instead, they signify greater needs should guide equitable national health policy.

Adolescent↗
PubMed1998

Estimating risk associated with care in alternative settings: deterioration among children hospitalized.

BACKGROUND: Although managed care favors use of alternative settings in an attempt to avoid hospitalization, uncertainty about possible deterioration creates concern about their safety. OBJECTIVE: To derive preliminary estimates for the risk of adverse outcome in children hospitalized with acute illness who met criteria for admission to potentially less-expensive, alternative settings (eg, short-stay unit, home nursing). DESIGN: Description of hospitalization outcomes for a community-wide childhood population. SETTING AND POPULATION: All 11591 hospitalizations for residents of Monroe County (Rochester), New York, aged 1 month to 18 years in 1991 and 1992. MEASUREMENTS: To identify potential adverse outcomes in alternative settings (numerator estimate), hospital medical records for admissions to regular inpatient units were examined. To ascertain deterioration among these admissions, detailed record reviews were conducted if the child died or was transferred to another hospital or to a critical care unit. To estimate the total number of admissions eligible for care in alternative settings (denominator estimate), hospital discharge files were analyzed. RESULTS: Deterioration was found in 83 medical admissions. Of these 83, major chronic problems (n=53) or severe illness at presentation (n=27) precluded alternative setting eligibility, leaving only 3 in whom alternative setting care might have been considered. The total number of admissions eligible for alternative setting care was estimated between 1661 (restrictive criteria) and 3322 (inclusive criteria) for the 2-year observation period. Based on these observations, best- and worst-case estimates for the risk of deterioration in candidates for care in alternative settings were 0.6 and 1.8 per 1000, respectively. For the 3 children for whom alternative setting care might have been considered, the shortest period from first indication of deterioration to arrival in the critical care unit was 3.0 hours. CONCLUSIONS: These preliminary estimates suggest that alternative settings may be safe for the care of many children currently hospitalized. A randomized clinical trial to evaluate directly the potential benefits and harms of alternative setting care should be considered.

Adolescent↗
PubMed1998

Diagnostic clusters in infants as child health outcomes. Variation among socioeconomic areas in one community.

Objectives were to examine geographic variation in rates of infant hospitalization for diagnostic clusters in Monroe County (Rochester), New York and to assess these clusters as indexes of child health. ICD-9 codes were used to cluster all 7,883 hospitalizations of infants (< 24 months) between 1985 and 1991 on the basis of their avoidability. Environmentally sensitive clusters accounted for 63% of admissions. These clusters included environmental, environmental/constitutional, and other infectious disease. Disparities in morbidity between inner city and suburbs were greatest for the environmental cluster, followed by the environmental/constitutional, and other infectious disease clusters. For the constitutional and quality indicator clusters, differences between inner-city and suburban risk were minimal. Environmental interventions may be more important than improved health services to reducing racial and economic disparities in child health. Analysis of morbidity clusters, ascertained from available administrative data bases and aggregated for small geographic areas, may guide child health policy well.

Cluster Analysis↗
PubMed1998

Resident and family continuity in pediatric continuity clinic: nine years of observation.

OBJECTIVE: To assess resident, patient, and family continuity. BACKGROUND: Continuity clinic is the principal longitudinal primary care experience for pediatric residents. Although it has been a recommendation of the Residency Review Committee for pediatric training for more than 10 years and has been a requirement of the Accreditation Council of Graduate Medical Education since 1989, the extent to which continuity is achieved in this setting has not been reported. METHODS: Nine years (1984-1993) of residents' continuity clinic experience in a community hospital affiliate of a university training program were reviewed. Continuity was defined by recurring visits between the same patient/provider pair. The analysis from 57 different residents includes 48 intern (R1) years, 45 level two (R2) years, and 40 level three (R3) years; 32 of these residents completed all 3 years of training (3-year cohort) in the program during the study period. Observations included 89 952 visits by 11 009 patients in 7130 families. Continuity was determined for the resident, patient, and family. RESULTS: Residents saw an annual average of 93, 136, and 144 visits as R1s, R2s, and R3s. Residents saw 60% of their patients fewer than 3 times and nearly 40% only once. In the final year for those in the 3-year cohort, residents saw an average of 149 visits; 53% of the time these R3s had seen their patients once or twice over 3 years. Thirty percent of the patients never saw their primary care physician (PCP) and 72% of patients had fewer than 3 visits with their PCP. One quarter of the families never saw their continuity resident, and 62% saw their continuity resident fewer than 3 times. CONCLUSIONS: These data demonstrate a remarkable lack of both resident and patient continuity in the principal clinical activity affording longitudinal primary care experiences during residency training. If more continuity is essential for both primary care of patients and education in general pediatrics, change in the structure of continuity experience is required.

Continuity of Patient Care↗
PubMed1997

Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial.

CONTEXT: Interest in home-visitation services as a way of improving maternal and child outcomes has grown out of the favorable results of a trial in semirural New York. The findings have not been replicated in other populations. OBJECTIVE: To test the effect of prenatal and infancy home visits by nurses on pregnancy-induced hypertension, preterm delivery, and low birth weight; on children's injuries, immunizations, mental development, and behavioral problems; and on maternal life course. DESIGN: Randomized controlled trial. SETTING: Public system of obstetric care in Memphis, Tenn. PARTICIPANTS: A total of 1139 primarily African-American women at less than 29 weeks' gestation, with no previous live births, and with at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed). INTERVENTION: Nurses made an average of 7 (range, 0-18) home visits during pregnancy and 26 (range, 0-71) visits from birth to the children's second birthdays. MAIN OUTCOME MEASURES: Pregnancy-induced hypertension, preterm delivery, low birth weight, children's injuries, ingestions, and immunizations abstracted from medical records; mothers' reports of children's behavioral problems; tests of children's mental development; mothers' reports of subsequent pregnancy, educational achievement, and labor-force participation; and use of welfare derived from state records. MAIN RESULTS: In contrast to counterparts assigned to the comparison condition, fewer women visited by nurses during pregnancy had pregnancy-induced hypertension (13% vs 20%; P=.009). During the first 2 years after delivery, women visited by nurses during pregnancy and the first 2 years of the child's life had fewer health care encounters for children in which injuries or ingestions were detected (0.43 vs 0.55; P=.05); days that children were hospitalized with injuries or ingestions (0.03 vs 0.16; P<.001); and second pregnancies (36% vs 47%; P=.006). There were no program effects on preterm delivery or low birth weight; children's immunization rates, mental development, or behavioral problems; or mothers' education and employment. CONCLUSION: This program of home visitation by nurses can reduce pregnancy-induced hypertension, childhood injuries, and subsequent pregnancies among low-income women with no previous live births.

Child Development↗
PubMed1997

Ensuring high-quality alternatives while ending pediatric inpatient care as we know it.

Child advocates recognize pediatric hospitalization as an issue of great concern because of the serious morbidity it reflects and the adverse psychosocial effects of inpatient experience on children and families. Accounting for almost 50% of child health care costs, estimated at $49.8 billion in the United States in 1987, pediatric hospitalization also represents a substantial financial burden. Studies of the variation in childhood hospitalization rates among geographic areas, however, suggest a large portion of these hospitalizations are avoidable. In individual level analysis, admitting pediatricians judged 28% of acute, general pediatric hospitalizations to be potentially avoidable had specified alternative services been available. Furthermore, evidence supports the safety of care in alternative settings for selected acute illness episodes. Hospitals share incentives for reducing inpatient services as they join managed care organizations that capitate hospital costs. At a time when health care cost reduction has become a dominant theme in industry and politics, concern seems warranted that cost considerations might prevail over quality considerations in shaping change. The concern of child advocates is heightened by the fact that costs are measured as dollars while measures of quality remain comparatively vague.

Child Advocacy↗
PubMed1997

Impact of an algorithm-guided nurse intervention on the use of immunization opportunities.

OBJECTIVE: To determine if a nurse intervention guided by an immunization algorithm was associated with an increased use of immunization opportunities at non-well-child care visits. DESIGN: A controlled intervention trial of an algorithm-guided nurse intervention during a 5-month period. The use of immunization opportunities at an intervention site was compared with the use at this site during the previous year (the retrospective control group) and with that at a similar pediatric practice during the same period (the concurrent control group). STUDY POPULATION: Children aged 2 to 60 months at 2 hospital-based pediatric practices that serve children of families with low to moderate incomes in Rochester, NY. RESULTS: During the study periods, 2814 study children in the 3 groups made 5464 visits for non-well-child care. The use of immunization opportunities for diphtheria-tetanus-pertussis vaccine, live oral poliovirus vaccine, and measles-mumps-rubella vaccine at intervention visits was significantly better than at the visits of the retrospective or concurrent control groups (range of odds ratios, 1.9-2.5). CONCLUSIONS: An algorithm-guided nurse intervention improved the use of immunization opportunities at non-well-child care visits.

Algorithms↗
PubMed1997

Decline of pediatric admissions with Haemophilus influenzae type b in New York State, 1982 through 1993: relation to immunizations.

OBJECTIVES: To evaluate the impact of vaccination for Haemophilus influenzae type b (Hib) on pediatric hospital admissions in New York State, and to identify risk factors in children who continue to be admitted for Hib invasive disease. METHODS: Retrospective review of hospitalizations in New York state from 1982 through 1993 and a survey of immunization records from physician offices in Monroe Country, New York. RESULTS: In 1982, 769 children were admitted to New York state hospitals for Hib-related conditions; by 1993, this had decreased to 133. Significant declines during the study period occurred in the age-adjusted admission rates for Hib meningitis, septicemia, pneumonia, and epiglottitis, but not for arthritis and osteomyelitis. In 1993 alone, 712 admissions, 18 deaths, and 135 episodes of morbidity were avoided. Since 1991, the rates of admissions for Hib-related conditions have remained fairly constant. Minority subjects continue to be twice as likely as white subjects to be admitted for invasive Hib disease (0.44 vs 0.17/100,000). Children living in urban Rochester also are more likely to be admitted and less likely to be completely immunized against Hib (61%) than those living in suburban areas (82%). CONCLUSIONS: Although Hib vaccine has had a major impact on hospital admissions for Hib-related conditions, the goal of completely eliminating Hib disease will require programs targeted at groups at high risk, such as minorities and those living in cities.

Adolescent↗
PubMed1997

Severity of respiratory syncytial virus infection is related to virus strain.

The relationship between respiratory syncytial virus (RSV) strain and disease severity was assessed in 265 hospitalized infants over a 3-year period (1988-1991). A severity index of clinical and physiologic parameters was used to grade illness severity. Multivariate analysis of 134 infants infected with group A RSV strains and 131 infants infected with group B strains indicated that prematurity, underlying medical conditions, group A RSV infection, and age < or =3 months were independently associated with severe disease. Odds ratios for severe disease for these risk factors were 1.83, 2.84, 3.26, and 4.39, respectively. Among infants without underlying medical conditions, group B RSV infection rarely required ventilatory support, in contrast to group A infections (1/90 vs. 13/107; P < .006), and had significantly lower severity indices (mean +/- SD, 0.6 +/- 9 vs. 1.3 +/- 1.9; P = .05). Results confirm earlier findings that group A RSV infection results in greater disease severity than group B infection among hospitalized infants.

Female↗
PubMed1997

Avoidable morbidity in infants. A classification based on diagnoses in administrative databases.

OBJECTIVES: A hierarchical classification for avoidable morbidity in infants was developed based on a conceptual model for causes of morbidity. Experts rated the impact of risk factors and health services on diseases coded according to the International Classification of Diseases, 9th Revision, Classification Modification (ICD-9-CM). An etiologic framework was chosen for the classification because knowledge of etiology often suggests strategies for prevention. Causes of morbidity that cluster on the basis of similar risk factors might be avoided using similar strategies. METHODS: Diseases (346 different diagnoses) were rated by 16 general pediatricians; 12 attributes were considered, including the impact on disease occurrence and on severity of five risk factors, preventive health services, and medical treatment. Raters evaluated the impact of health services, constitutional risk factors, and environmental risk factors without regard for service site (eg, inpatient, emergency department, primary care office). Environmental risk factors categories, including family, social, and physical environments, were rated separately. The impact of health services was rated on prevention, treatment, and complications of care. RESULTS: Only ratings indicating that the impact of a risk factor category was substantial were used for the final classification of 275 diagnoses. Consistent with the multifactorial etiology of many diseases, many diagnoses had ratings indicating substantial impact of multiple risk factors. Five mutually exclusive clusters were derived from the 12 ratings based on factor analysis and recognized strategies for prevention. Ordered by level of avoidability, these clusters were termed vaccine-preventable, health-care quality indicators, environmental, environmental/constitutional, and constitutional. CONCLUSIONS: The usefulness of this classification for policy-oriented epidemiologic and health services research is grounded in the premise that prevention is the cardinal objective of child health policy. Cluster-specific hospitalization rates, ie, rates aggregated for all diagnoses falling in a cluster, might be used for allocating resources to interventions directed at environmental or health service determinants of morbidity. Widespread use of ICD-9-CM codes in hospital discharge and ambulatory databases suggests many potential applications for this classification of morbidity burden in population groups.

Databases, Factual↗
PubMed1997

Socioeconomic variation in discretionary and mandatory hospitalization of infants: an ecologic analysis.

OBJECTIVES: To examine geographic variation in rates of infant hospitalization for diagnoses classified by type of hospitalization decision in Monroe County (Rochester), New York. METHODS: Study design was cross-sectional and ecologic. International Classification of Diseases (ICD) codes were used to categorize all 7883 hospitalizations for infants (age, <24 months) beyond the newborn period between 1985 and 1991. Postal zip codes defined socioeconomic areas as inner-city, other urban, and suburban for the population at risk. In 1990, inner-city infants included 62% black and 65% Medicaid-covered infants, whereas suburban infants included 3% black and 6% covered by Medicaid. Hospitalization rates were compared among the three socioeconomic areas. RESULTS: Overall hospitalization rate was 50.3 per 1000 child years. Admissions classified as discretionary accounted for 59% of these, followed by those classified as mandatory, 18%; sometime (congenital heart disease, cleft palate), 15%; discretionary surgery (inguinal hernia, tonsillectomy/adenoidectomy), 6%; and unlikely to need admission, 2%. A stepwise, socioeconomic gradient in hospitalization was found, with rates of 38.1, 51.3, and 82.9 per 1000 child-years, respectively, for suburban, other urban, and inner-city areas. Rates for discretionary, unlikely, and mandatory admissions followed this gradient. Using the odds for hospitalization of suburban infants as the base odds, the odds ratio for discretionary hospitalization for inner-city infants was 2.88 (95% confidence interval [CI], 2.69 to 3. 08) and that for mandatory hospitalization was 2.20 (95% CI, 1.94 to 2.49). In multiple regression analysis, low education level of mothers explained 81% of the variance in discretionary hospitalization rate. Although the per capita rate of hospital care of inner-city infants was more than twofold greater than that for suburban infants, potential for reducing this difference is suggested by the fact that discretionary admissions accounted for 78. 9% of this difference, whereas mandatory admissions accounted for 17. 7% of the difference. CONCLUSION: The hospitalization rate for inner-city infants is much greater than that for suburban infants. A substantial portion of the difference, namely that attributable to mandatory admissions, reflected higher rates of serious illness. Differences attributable to discretionary admissions may reflect higher rates of serious illness to some extent, but also appear to reflect less effective health services to a substantial degree.

Cross-Sectional Studies↗
PubMed1996

Screening for tuberculosis infection in urban children.

OBJECTIVES: To determine the proportion of children who are at high risk for tuberculosis (TB) as defined by the American Academy of Pediatrics (AAP) criteria, the rate of compliance with visits for tuberculin skin test (TST) interpretation, and the prevalence of TB infection. DESIGN: A cross-sectional study of 401 children, 12 months to 18 years of age, who attended a hospital-based, urban pediatric clinic for well-child visits was undertaken from April 13, 1994, through August 30, 1994. Respondents completed a self-administered questionnaire, an intradermal TST was applied, and an appointment was scheduled for skin test interpretation in 48 to 72 hours. SETTING: Hospital-based, pediatric primary care center in Rochester, NY, serving children of low to moderate income (67% were receiving Medicaid). RESULTS: Of the 401 children, 342 (85%) had at least 1 risk factor for TB identified: 96 (24%) reported contact with persons who were considered to be at high risk for TB; 170 (42%) had at least 1 parent who was born in a high prevalence country; and 269 (67%) reported a household income of less than $15,500. Of the 401 children, 300 returned for TST interpretation, 257 (64%) by 48 to 72 hours and an additional 43 (11%) by 96 hours. Four (1.3%) of the 300 children had a positive TST (ie, induration > or = 10 mm). All 4 of the children who were TST positive had at least 1 parent from a high-risk country and were identified using AAP-defined risk criteria. The mean age of children who were TST positive was 15.3 years (range 13-17 years) compared with 8.1 years for those who were TST negative (P < .01). The positive predictive value of the questionnaire, which included income as a risk factor for TB, was only 1.5 (95% confidence interval = 0.5-4.0); when household income was not considered a risk factor, the positive predictive value was 2.0 (95% confidence interval = 0.7, 5.5). The estimated cost per child who was TST positive ranged from $430 for those who had contact with an incarcerated adult to $855 per child who was TST positive identified by using AAP-defined criteria. CONCLUSIONS: The overall sensitivity of the AAP-defined criteria and having at least 1 parent from a TB-endemic country were high. However, because of the low prevalence of TB infection, the positive predictive value of these criteria was very low. These data support AAP recommendations only to skin test children who are at high risk for TB, but they also suggest that annual testing may not be cost-effective for many communities in the United States.

Adolescent↗
PubMed1995

Hospitalization for lower respiratory tract illness in infants: variation in rates among counties in New York State and areas within Monroe County.

OBJECTIVE: Lower respiratory tract illness (LRI) is the most common serious illness in childhood and the most common reason for hospitalization of infants beyond the neonatal period. This study assessed the potential for cost savings from reduction in hospitalization for LRI. SETTING AND SAMPLE: LRI hospitalization rates for children in the first 2 years of life (infants) were studied for the 62 counties of New York State and six socioeconomic areas within Monroe County (Rochester) for the years 1985 through 1991. DESIGN: Analysis of small area variations. RESULTS: LRI accounted for 51.2% of infant hospitalizations in New York State. The overall LRI hospitalization rate for New York's 62 counties was 27.0 per 1000 child-years and ranged, among the 18 most populous counties, from 10.7 for Monroe County to 39.3 for the Bronx. Unemployment rate was the strongest predictor of LRI hospitalization rates for counties, explaining 29% of the variance in multiple regression analysis. Within Monroe County, LRI hospitalization rates followed a geographic gradient from the inner city (22.5) to the rest of the city (12.2), and to the suburbs (7.3). Deaths from LRI were uncommon (0.36% of state LRI hospitalizations) and varied little between inner city (0.42%) and suburbs (0.51%). If LRI hospitalization rates for Monroe County suburban children prevailed for the entire state, 10,439 hospitalizations and $32,916,000 would be saved annually. CONCLUSIONS: A large portion of the increased cost of health care for children living in poverty is attributable to hospitalization for LRI in infants. Physician discretion in decision making and factors associated with socioeconomic status are probably major determinants of variation. Well-coordinated follow-up of acute illness visits, home monitoring by visiting nurses, and empirically based clinical guidelines for management of LRI might yield both substantial cost savings and better service to families.

Costs and Cost Analysis↗
PubMed1994

Lead screening among high-risk urban children. Are the 1991 Centers for Disease Control and Prevention guidelines feasible?

OBJECTIVE: To determine whether the 1991 Centers for Disease Control and Prevention lead poisoning prevention guidelines for biannual screening and retesting are feasible among a high-risk population. METHODS: For 632 urban high-risk children aged 9 to 25 months who used a pediatric primary care center between 1989 and 1991, we assessed physician screening practices and the need to increase utilization to meet guidelines for retesting. Analysis also focused on missed opportunities for lead screening. For 425 urban high-risk children who were long-term utilizers of the center, we assessed the need to increase utilization to meet guidelines for biannual screening. RESULTS: Screening was not up to date in 55%, 34%, and 29% of children at ages 9 to 13 months, 14 to 19 months, and 20 to 25 months, respectively. These children had a mean of 2.3, 2.5, and 2.3 missed opportunities during each age period. Among children who had made well-child visits, in 41%, 36%, and 28% of children screening was not up to date at each age period. Between ages 13 and 37 months, 42% of long-term clinic utilizers made sufficient visits to achieve biannual screening. Sixty-five percent of children who were screened made a subsequent visit within 2 to 5 months, at which time retesting could have been performed. CONCLUSIONS: At this primary care center, many high-risk children, including those who had made well-child visits, were not appropriately screened for lead toxic effects. Children not screened had many missed opportunities at all types of visits, including well-child visits. Many children visited frequently enough to achieve biannual screening and retesting without increased numbers of visits if non-well-child visits had been used as opportunities for retesting.

Centers for Disease Control and Prevention, U.S.↗
PubMed1992

Immunization opportunities missed among urban poor children.

Low immunization rates among US preschool children suggest a need for improved immunization practices. Immunization and encounter records were reviewed to ascertain immunization rates and missed opportunities for vaccine administration among 515 preschool children who were active patients at a hospital-based primary care center serving lower socioeconomic status families in Rochester, NY. The point prevalence at a mean age of 4.4 years for lack of one or more recommended immunizations was 27%; 7% were missing measles-mumps-rubella, 18% were missing Haemophilus influenzae type b, 8% were missing two or more diphtheria-tetanus-pertussis, and 4% were missing two or more oral poliovirus immunizations. A visit was counted as a missed opportunity if an immunization was due but not given. Over the period from birth through age 36 months, 422 (82%) of children missed at least one immunization opportunity. For these 422 children, there was a mean of 7.2 missed opportunities per child. Although 64% of missed opportunities occurred at an acute illness visit, 36% occurred at well-child, administrative, follow-up, or chronic illness visits. Review of 200 medical records randomly selected from all opportunities at acute illness visits found no contraindication in 63% (50% nonfebrile infectious disease, 13% minor noninfectious problems). Findings for random samples of 100 missed diphtheria-tetanus-pertussis opportunities for children aged 2 to 6 months and 100 missed measles-mumps-rubella opportunities for children 15 to 24 months were similar to findings for the sample of all acute illness visits. Emergency department visits, where immunization records were not readily available, accounted for 18% of missed opportunities.(ABSTRACT TRUNCATED AT 250 WORDS)

Algorithms↗
PubMed1990

Variation in severity of respiratory syncytial virus infections with subtype.

Two major subtypes of respiratory syncytial virus have been identified. This study assessed the hypothesis that A-subtype infections were more severe than B-subtype infections among the 157 infants hospitalized in two hospitals in Rochester, N.Y., during two winters. Severity was measured both by specific clinical observations and by a severity index that was derived empirically. Among all subjects, several clinical observations suggested that A-subtype infections were more severe. For example, mechanical ventilation was required in 12.6% of those with A-subtype compared with 1.6% of those with B-subtype infection (relative risk = 7.88; p = 0.01). Among high-risk infants (infants with underlying conditions or age 3 months or less at admission), carbon dioxide tension greater than 45 mm Hg was found in 37.0% of those with A-subtype compared with 12.0% of those with B-subtype infection (relative risk = 3.08; p = 0.04). In discrete multivariate (logit) analysis, effects of subtype (odds ratio = 6.59; p less than 0.01) on severity remained after adjustment for other statistically significant effects of age less than 3 months, underlying condition, and premature birth. The finding that A-subtype infections were more severe might have important implications for vaccine development, studies of the virulence of respiratory syncytial virus, clinical management (e.g., selection for antiviral therapy), and long-term prognosis.

Age Factors↗