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Objectives Individuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living). Design We performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents. Setting and participants We studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia. Measures We compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services. Results Intervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96). Conclusions/Implications Telemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.

To assess the hypothesis that effectiveness and safety of the Health-e-Access telemedicine model for care of children with special healthcare needs (CSHCN) with acute illness equaled those for care of children in regular childcare and schools (CRS).We examined healthcare use through insurance claims and telemedicine records spanning 5.7 and 7.3 years for CSHCN and CRS, respectively. Effectiveness was measured as telemedicine visit completion, duplication, and adverse events. Completed visits had diagnosis and management decisions made, and treatment implemented, based solely on telemedicine. Duplicating visits addressed related problems in-person following telemedicine visits within 1 or 3 days. An adverse event was defined as an emergency department visit following a telemedicine visit within 3 days for a problem probably related.Comparisons addressing these measures included 483 and 10,008 telemedicine visits by CSHCN and CRS, respectively. Claims files captured health services use for varying periods of time among 300 different CSHCN and among 1,950 different CRS. Among the 483 telemedicine visits initiated for CSHCN over their telemedicine observation period, 9 were not completed. The CSHCN completion rate of 98.1% equaled the 97.6% completion observed among CRS. Within 3 days, in-person visits duplicated 16.1% of telemedicine visits for both CSHCN and CRS. Within 1 day, in-person visits duplicated 5.3% and 8.9% of telemedicine visits for CSHCN and CRS, respectively. Adverse events following telemedicine visits included 0.3% of telemedicine visits for CSHCN and 0.5% for CRS.Observations support safety and effectiveness of Health-e-Access telemedicine for both CSHCN and CRS.

In the spirit of Dr. Haggerty's teachings, we present an overview of our work to improve care for children with asthma in the context of 3 lessons learned: 1) the importance of providing integrated services across disciplinary boundaries for children with chronic illness, 2) the need to move from a care model focused only on the individual child to a model focused on the child, family, and community, and 3) the need to expand beyond the local community and take a broad perspective on improving health on a national level. The goal of our program is to develop sustainable models to overcome the multiple obstacles to effective preventive care for urban children with asthma. The primary intervention for our original School-Based Asthma Therapy program was directly observed administration of preventive asthma medications in school (with dose adjustments on the basis of National Heart, Lung, and Blood Institute guidelines). We found that children who received preventive medications in school through directly observed therapy had improved outcomes across multiple outcome measures. Our subsequent asthma programs have focused on dissemination and sustainability, with the incorporation of communication technology to enhance the system of care. We are currently testing the 'School-Based Telemedicine Enhanced Asthma Management' program, including 400 children with persistent asthma from the Rochester City School District. This program includes directly observed administration of preventive asthma medication at school, and school-based telemedicine to assure appropriate evaluation, preventive medication prescription, and follow-up care. It is designed to implement and sustain guideline-based asthma care through existing community infrastructure, and could serve as a model for the integration of services in rural as well as urban communities.

Background: Telemedicine has enhanced care for children with illness in Rochester, NY, since May 2001, enabling 13,568 acute illness visits through December 2013. Prior findings included high parent satisfaction with childcare- and school-based telemedicine (“school telemedicine”) and potential to replace 85% of office visits for illness. Urban neighborhood telemedicine (“neighborhood telemedicine”) was designed to offer convenient care for illness episodes that school telemedicine often cannot serve because illness arises when children are at home or symptoms preclude attendance. This study was designed to characterize health problems prompting neighborhood telemedicine use and to assess parent perceptions of its value. Materials and Methods: A parent satisfaction instrument was developed with input from parents and providers. Neighborhood telemedicine was initiated in January 2009 and totaled 1,362 visits through November 2013. During a 29-month survey period through January 2012, 3,871 acute illness telemedicine visits were completed, 908 (23.5%) of them via neighborhood telemedicine. Instruments were completed for 392 (43.2%) of the 908 visits. Results: Neighborhood telemedicine comprised 27% of all telemedicine visits during the year of peak neighborhood activity. Almost all survey respondents were satisfied or highly satisfied with neighborhood visits (97.6%) and endorsed greater convenience than alternatives (94.5%). Conclusions: Family preferences and the high value placed on neighborhood telemedicine suggest such service is important, especially in health systems driven by patient values. Service provided by neighborhood telemedicine holds potential to meet a large demand for care of acute childhood illness. Financing reform to support patient-centered care (e.g., bundled payments) should encompass sustainable business models for this service.

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models.

Children with care for acute illness available through the Health-e-Access telemedicine model at childcare and schools were previously found to have 22% less emergency department (ED) use than counterparts without this service, but they also had 24% greater acute care use overall.We assessed the hypothesis that increased utilization reflected improved access among impoverished inner-city children to a level experienced by more affluent suburban children. This observational study compared utilization among children without and with telemedicine access, beginning in 1993, ending in 2007, and based on 84,287 child-months of billing claims-based observation.Health-e-Access Telemedicine was initiated in stepwise manner over 187 study-months among 74 access sites (childcare, schools, community centers), beginning in month 105. Children dwelled in inner city, rest-of-city Rochester, NY, or in surrounding suburbs. Rate of total acute care visits (office, ED, telemedicine) was measured as visits per 100 child-years. Observed utilization rates were adjusted in multivariate analysis for age, sex, insurance type, and season of year.When both suburban and inner-city children lacked telemedicine access, overall acute illness visits were 75% greater among suburban than inner-city children (suburban:inner-city rate ratio 1.75, p 0.0001). After telemedicine became available to inner-city children, their overall acute visits approximated those of suburban children (suburban:inner-city rate ratio 0.80, p = 0.07), whereas acute visits among suburban children remained at least (worst-case comparison) 56% greater than inner-city children without telemedicine (rate ratio 1.56, p 0.0001).At baseline, overall acute illness utilization of suburban children exceeded that of inner-city children. Overall utilization for inner-city children increased with telemedicine to that of suburban children at baseline. Without telemedicine, however, inner-city use remained substantially less than for suburban counterparts.Health-e-Access Telemedicine redressed socioeconomic disparities in acute care access in the Rochester area, thus contributing to a more equitable community.

Importance Poor adherence to recommended preventive asthma medications is common, leading to preventable morbidity. We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program to build on school-based supervised therapy programs by incorporating telemedicine at school to overcome barriers to preventive asthma care. Objective To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma. Design, Setting, and Participants In this randomized clinical trial, children with persistent asthma aged 3 to 10 years in the Rochester City School District in Rochester, New York, were stratified by preventive medication use at baseline and randomly assigned to the SB-TEAM program or enhanced usual care for 1 school year. Participants were enrolled at the beginning of the school year (2012-2016), and outcomes were assessed through the end of the school year. Data were analyzed between May 2017 and November 2017 using multivariable modified intention-to-treat analyses. Interventions Supervised administration of preventive asthma medication at school as well as 3 school-based telemedicine visits to ensure appropriate assessment, preventive medication prescription, and follow-up care. The school site component of the telemedicine visit was completed by telemedicine assistants, who obtained history and examination data. These data were stored in a secure virtual waiting room and then viewed by the primary care clinician, who completed the assessment and communicated with caregivers via videoconference or telephone. Preventive medication prescriptions were sent to pharmacies that deliver to schools for supervised daily administration. Main Outcomes and Measures The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews. Results Of the 400 enrolled children, 247 (61.8%) were male and 230 (57.5%) were African American, and the mean (SD) age was 7.8 (1.7) years. Demographic characteristics and asthma severity in the 2 groups were similar at baseline. Among children in the SB-TEAM group, 196 (98.0%) had 1 or more telemedicine visits, and 165 (82.5%) received supervised therapy through school. We found that children in the SB-TEAM group had more symptom-free days per 2 weeks postintervention compared with children in the enhanced usual care group (11.6 vs 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01), with the largest difference observed at the final follow-up (difference, 0.85; 95% CI, 0.10-1.59). In addition, children in the SB-TEAM group were less likely to have an emergency department visit or hospitalization for asthma (7% vs 15%; odds ratio, 0.52; 95% CI, 0.32-0.84). Conclusions and Relevance The SB-TEAM intervention significantly improved symptoms and reduced health care utilization among urban children with persistent asthma. This program could serve as a model for sustainable asthma care among school-aged children. Trial Registration clinicaltrials.gov Identifier:NCT01650844

High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates.We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services.During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction).Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

The ready access provided by telemedicine benefits families and society but might increase total healthcare utilization with uncertain implications for costs. The objective of this study was to assess the net impact on healthcare utilization of introducing into inner-city childcare a telemedicine model designed to manage acute illness. A cohort study was done using comparable periods before and after introduction of telemedicine for all qualifying children (n = 112) using three innercity childcare centers. Because the utilization histories of these children differed in length, we chose child-months as the unit of analysis. Acute illness visits were ascertained for 1806 child-months among the 112 qualifying children. Following telemedicine startup, children's office and emergency department (ED) visits for illness fell by 1.73 and 0.20/child/year, respectively, replaced by telemedicine visits at 1.07/year. These observations could be misleading, however, because of the possibility of confounding factors. For example, the cohort aged during observation, and illness visits fall with age. Accordingly, in multivariate analysis we adjusted for season of the year, age, and within-child correlation. In this analysis, reduction in illness utilization overall tended toward an increase (rate ratio = 1.26, p = 0.13). The worst-case estimate (based on upper 95% confidence interval for rate ratio) for increase in illness utilization was 3.38 visits/child/year, and the most likely case was an increase of 1.26. Assuming (1) the worst-case effect (largest increase) on overall utilization and (2) reimbursement for ED, office, and telemedicine visits of 350 dollars, 45 dollars, and 45 dollars, respectively, the healthcare system would break even on telemedicine if it replaced 0.50 ED visits per child annually.

This article describes the effective use of telemedicine for the urban adult patient. A successful pediatric telemedicine program was expanded to include care for adults. The pilot program resulted in high levels of patient satisfaction, decreased loss of work time, and decrease in inappropriate use of the emergency department.

1. Kenneth M. McConnochie, MD, MPH* 1. *Professor of Pediatrics and Director, Health-e-Access Telemedicine Program, The University of Rochester School of Medicine & Dentistry, Rochester, NY Invalidating assumptions about space and time, telemedicine holds profound implications for health care. Much about the current structure and organization of health services reflects the assumption that patient and clinician must be in the same place at the same time. Yet telemedicine commonly eliminates geography as a barrier to access, and much exchange of information need not occur synchronously. The potential for specific telemedicine applications to enable quality health care has been demonstrated using commercially available technology. The opportunity for children, families, and primary care pediatricians to gain from the access and effectiveness proffered by telemedicine hinges on its acceptance and adoption in the health-care system. Adoption, in turn, depends on successful organizational innovation, especially reimbursement from insurance organizations. This discussion emphasizes the potential benefits of telemedicine in primary care pediatric practice and the challenge of integrating this tool into that setting. In our view, the greatest promise for benefiting children and families lies in integrating telemedicine into primary care. Telemedicine is defined by the American Telemedicine Association (ATA) as “the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care.” Although encompassing many applications beyond our purview (eg, teledermatology, telepathology, educational teleconferences, telecardiology, telemental health, virtual critical care units), (1) this broad definition is notable from the perspective of the primary care pediatrician because it rightfully includes practice via telephone. From a clinical perspective, telephone practice and more advanced forms of telemedicine are close kin because a required competency for both is the ability to judge whether available information is sufficient for diagnosis and management. As in telephone practice, the need to refer to a traditional, in-person care setting for hands-on, laboratory, or imaging evaluation is always …

For the purpose of reducing the social and economic burden imposed by common acute childhood illness, we developed a telemedicine model to enable diagnosis and treatment of illness episodes presenting in pediatric office settings. The study objective was to assess the effectiveness of this telemedicine model in replacing illness visits to traditional healthcare settings and to compare effectiveness of this model (base model) with that of alternative models including simple office laboratory tests and albuterol administration (simple model) or a complete complement of tests and procedures (extended model). Eligible subjects had an acute problem and were seen in the pediatric primary care practice or pediatric emergency department of the University of Rochester Medical Center. All subjects were seen by the setting's usual physician. Subjects were also evaluated, based on random assignment, by a study physician in person or by a study physician via telemedicine. Effectiveness was defined as completion of the visit to the point that diagnosis was made. Forms completed by study physicians, and standard medical records indicating the tests and procedures requested for the purpose of completing the visit, were used to identify the model used in completing the visit. Effectiveness (proportion of visits completed) of the base model was assessed and its effectiveness was compared to that of simple and extended telemedicine models. Among 520 randomized visits, 492 were evaluated by study physicians in person (253) or via telemedicine (239). Using the base model, study physicians completed 74.1% of visits via telemedicine compared to 76.7% for study physicians in person and 76.0% for usual physicians. The simple model increased completion rates substantially. Using this model, study physicians completed 84.9% of visits via telemedicine compared to 86.6% for study physicians in person and 85.2% for usual physicians. The extended model increased effectiveness in completing visits still more, with telemedicine study physicians completing 97.1% of visits compared to 96.8% for in-person study physicians and 100% for usual physicians. Approximately 85% of illness visits presenting to primary care pediatric practice could be completed using a telemedicine model that included only simple office laboratory testing and albuterol administration.

Background.—Pediatricians elicit information about asthma control from parents to help formulate management plans. If parents of children with significant asthma symptoms inappropriately indicate good control, physician recommendations may not be optimal. We examined whether a single general question about asthma control might lead to inaccurate assessment of severity. Design/Methods.—Children 3–7 years of age who met the National Heart, Lung, and Blood Institute (NHLBI) criteria for mild persistent to severe asthma were identified from 40 urban schools. A phone survey of their parents provided demographic information, symptom frequency, medication use, and general interpretation of their child's asthma control. Chi-square analyses compared the parent's general interpretation of control with demographic characteristics and measures of asthma severity. Results.—One hundred sixty of 224 eligible children participated in this study. Seventy-eight percent were described as in good asthma control. General assessment of asthma control did not vary by demographic characteristics. Parents were as likely to describe children with daily asthma symptoms in good control as they were to describe children with less frequent symptoms in good control. Parents were less likely to report good control in children using daily rescue medications when compared with children with less frequent medication use (65% vs 82%, P = .03), but the majority of children in both groups was described as having good control. Conclusions.—Most parents underestimated the severity of their child's asthma and reported good control with their global assessment. Parents frequently reported good control even when the children had daily asthma symptoms. Pediatricians should ask about specific asthma symptoms during patient encounters because a global question about asthma control likely will result in underestimations of asthma severity.

Objective. Personal health records (PHRs) may address the needs of children with attention deficit hyperactivity disorder. Among parents, we assessed acceptance, barriers, and intentions regarding use of PHR for their children with attention deficit hyperactivity disorder. Methods. Survey of parents from 3 practices in Rochester, NY. Stepwise logistic regression analysis explored factors predicting respondents’ intentions for future use of PHR, accounting for care coordination needs, caregiver education, socioeconomic status, and satisfaction with providers. Results. Of 184 respondents, 23% had used the PHR for their child, 82% intended future use. No difference was observed between users and nonusers regarding gender, age, race, or education. Users were more likely than nonusers to reside in the suburbs ( P = .03). Caregivers were more likely to plan future use of the PHR if they felt engaged as partners in their child’s care (adjusted odds ratio = 2.3, 95% confidence interval = 1.2, 4.5). Conclusions. Parents are enthusiastic about PHRs. Future work should focus on engaging them as members of the health care team.

Background. Congenital diaphragmatic hernia (CDH) is a malformation of the diaphragm that allows bowel to enter the thoracic cavity, resulting in pulmonary hypoplasia and pulmonary hypertension. Approximately 50% of CDH patients are treated with extracorporeal membrane oxygenation (ECMO). The optimal gestational age for delivery of term infants with CDH at high risk for requiring ECMO is not known. The goal of this study was to compare survival of infants with CDH receiving ECMO born early term (38 0/7-39 6/7 weeks' gestation) with those born late term (40 0/7-41 6/7 weeks' gestation). Changes in survival rates of term infants and the factors associated with these changes were assessed over the 25 years that ECMO has been available. Methods. Design. Retrospective cohort study of infants with CDH treated with ECMO. Data Sources. The Extracorporeal Life Support Organization registry of patients treated at active Extracorporeal Life Support Organization centers from April 1976 through June 2001. Analysis. Survival and clinical predictors of survival were compared between infants born early term (38 0/7-39 6/7 weeks' gestation) and infants born late term (40 0/7-41 6/7 weeks' gestation). Changes in survival rates over time and factors associated with survival were evaluated. Results. Among full-term infants with CDH treated with ECMO, late-term compared with early-term delivery was associated with improved survival (63% vs 53%). Among full-term survivors of ECMO, late-term infants spent less time on ECMO (181 vs 197 hours) and less time in the hospital (60 vs 67 days). In multivariate analysis, greater birth weight, higher 5-minute Apgar score, higher arterial pH and Pco 2

Background.Asthma morbidity and mortality has increased substantially in recent years, but asthma hospitalization rates among many geographic and sociodemographic groups have remained stable. Observations on asthma hospitalization rates and severity of acute episodes might provide valuable insight into the functioning of the health care system during this period of health care reform.Objective.To analyze changes between 1991 and 1995 in childhood asthma hospitalization rates and severity of acute episodes.Design and Methods.All 29 329 hospitalizations, including 2028 for asthma, for the 198 893 children (Results.Hospitalization rates are expressed as hospitalizations per 1000 child-years. The overall asthma hospitalization rate was 2.04 (95% confidence interval, 1.95–2.13). The overall annual asthma hospitalization rate remained relatively stable from 1991 (1.90) to 1995 (2.31), whereas the hospitalization rates for severe asthma rose 270%—from 0.57 to 1.55—during this period. Simultaneously, the hospitalization rates for mild asthma decreased from 0.26 to 0.12. As a proportion of all asthma hospitalizations between 1991 and 1995, severe episodes increased from 31.5% to 60.4%; conversely, mild episodes decreased from 14.1% to 4.7%.Conclusions.Severity increased significantly among children hospitalized for asthma while the overall asthma hospitalization rate remained stable. It seems that the health care system in this community has responded to an increase in severity of asthma by raising the severity threshold for admission.

OBJECTIVE. Health-e-Access, a telemedicine service providing care for acute illnesses in children, has delivered >6500 telemedicine visits from 10 primary care practices in Rochester, New York, by using telemedicine access at 22 child care and school sites. The goal was to assess the hypotheses that children served by Health-e-Access received health care more often for acute illnesses but had fewer emergency department (ED) visits and lower health care expenditures than did children without access through this service.METHODS. By using insurance claims, this case study compared utilization (starting in May 2001) of telemedicine, office, or ED care for children with versus without telemedicine access. Children included in analyses had ≥6 consecutive insurance-covered months through July 2007. Claims data captured all utilization. A total of 19 652 child-months from 1216 children with telemedicine access were matched with respect to age, gender, socioeconomic status, and season with child-months for children without telemedicine availability.RESULTS. The mean age at utilization was 6.71 years, with 79% of all child-months being covered by Medicaid managed care. The overall utilization rate was 305.1 visits per 100 child-years. In multivariate analyses with adjustment for potential confounders, overall illness-related utilization rates (in-person or telemedicine visits per 100 child-years) for all sites were 23.5% greater for children with telemedicine access than for control children, but ED utilization was 22.2% less.CONCLUSION. The Health-e-Access telemedicine model holds potential to reduce health care costs, mostly through replacement of ED visits for nonemergency problems.

Background Guidelines recommend that children with mild persistent to severe persistent asthma receive maintenance anti-inflammatory medications. However, providers may not be aware of the severity of their patients' symptoms. The underestimation of severity may contribute to poor adherence to asthma care guidelines. Objectives To describe the use of preventive medications among a group of urban children with mild persistent to severe persistent asthma and to evaluate the degree to which their health care providers are aware of their asthma severity. Design Children (ages 4-6 years) from urban schools in Rochester, NY, were eligible if their parents reported mild persistent to severe persistent asthma symptoms. Each child's health care provider was asked to assess the child's asthma severity and use of medications based both on their knowledge of the child and review of the medical record. Parent and provider assessments were compared. Bivariate and regression analyses were used to identify factors associated with concordant classifications of asthma severity. Results Ninety children with parent-defined mild persistent to severe persistent asthma participated (64% boys, 67% black, 73% receiving Medicaid). Only 40% of the children were described accurately by their providers as having mild persistent to severe persistent asthma, and only 50% of the total had been prescribed maintenance medications. Thirty-six percent of families reported that their child used maintenance medications daily. In contrast, most of the children who were classified by their provider as having mild persistent to severe persistent asthma were prescribed a maintenance medication (83%), and 58% used them daily. Sociodemographic characteristics and asthma severity were not associated with provider accuracy. Conclusions Most children in this study were not accurately classified by their providers as having mild persistent to severe persistent asthma and had not been prescribed maintenance medications. When providers were aware of their patient's asthma symptoms, most of the children were prescribed maintenance medications. Attempts to improve adherence to asthma guidelines should take into consideration provider underestimations of asthma severity.

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.Descriptive study based on analysis of hospital discharge files and on retrospective medical record review of a random sample of asthma hospitalizations.The 2028 asthma hospitalizations between 1991 and 1995 for children (aged19 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.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.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.

In this issue of Neurology ®, The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS)1 adds noteworthy information about using emerging communication technology and organizational innovation to optimize treatment of acute ischemic stroke (AIS) in the general population, regardless of geographic location. Based on the largest published telemedicine for AIS data set to date, long-term mortality rates and functional outcomes (at 3 and 6 months) for telestroke-enabled community hospitals using recombinant tissue plasminogen activator (rt-PA) were similar and comparable to the results of previous trials.2 Their data suggest that less experienced physicians in 12 community hospitals, guided remotely by stroke experts who are informed through a telemedicine model that included video/audio conferencing and transmission of CT images, can achieve the same results the stroke experts obtain in their own centers. The telemedicine model included 24/7 remote support from two hubs that were committed to initiate telestroke consultation within 3 minutes after telephone contact. Remarkably, rt-PA use in the community hospitals increased 10-fold because of telemedicine. To place these findings in context, without treatment, a typical large vessel AIS kills roughly 2 million neurons, 14 billion synapses, and over 7 miles of myelinated fibers each minute.3 IV rt-PA quadruples the likelihood of minimum or no disability when a patient …

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 County, 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. (J Pediatr 1997;130:923-30)

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.

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. (Arch Pediatr Adolesc Med. 1994;148:688-693)

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 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 The overall asthma hospitalization rate was 2.04 admissions/1000 child-years. Children Based on worst Sao2 values, mild (worst Sao2 ≥95%), moderate (90%–94%), and severe (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.

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.

Background Guidelines recommend preventive medications for all children with persistent asthma, yet young urban children often receive inadequate therapy. This may occur in part because primary care providers are unaware of the severity of their patients’ symptoms. Objective To determine whether systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, will prompt providers to take preventive medication action (prescribe a new preventive medication or change a current dose). Design Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2002-2003 school year in Rochester. Children were assigned randomly to a provider notification group (child’s primary care provider notified of asthma severity) or a control group (provider not notified of severity). Primary care providers of children in the provider notification group were sent a facsimile indicating the child’s symptoms and recommending medication action based on national criteria. Interviewers blinded to the child’s group assignment called parents 3 to 6 months later to determine if preventive actions were taken. Results Of 164 eligible children with mild persistent or more severe asthma, 151 (92.1%) were enrolled. Children in the provider notification group were not more likely to receive a preventive medication action than were children in the control group (21.9% vs 26.0%; P = .57). Additional preventive measures, including encouraging compliance with medications (33.3% vs 31.3%; P = .85), recommending environmental modifications (39.3% vs 42.4%; P = .86), and referrals for specialty care (6.6% vs 6.0%; P > .99), also did not differ between the provider notification and control groups. At the end of the study, 52.4% of children in both groups with no medication changes were still experiencing persistent symptoms. Conclusions School-based asthma screening identified many symptomatic children in need of medication modification. Provider notification, however, did not improve preventive care. Findings suggest that more powerful interventions are needed to make systematic asthma screening effective.

Background Daily maintenance medications are recommended for all children with mild persistent to severe persistent asthma; however, poor adherence to these medications is common. Objective To evaluate the impact of school-based provision of inhaled corticosteroids on asthma severity among urban children with mild persistent to severe persistent asthma. Design Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2000-2001 and 2001-2002 school years in Rochester. Children were assigned randomly to a school-based care group (daily inhaled corticosteroids provided through the school) or a usual-care group (inhaled corticosteroids not given through school). Main Outcome Measure Improvement in parent-reported symptom-free days. Results Of 242 eligible children, 184 were enrolled from 54 urban schools. Data for 180 children were available. Parents of children in the school-based care group had a greater improvement in quality of life compared with parents of children in the usual-care group (change score, 0.63 vs 0.24;P= .047); also, children in the school-based care group vs the usual-care group missed less school because of asthma (mean total days missed, 6.8 vs 8.8;P= .047) and experienced more symptom-free days during the early winter months (mean days per 2-week period, 9.2 vs 7.3;P= .02). A post hoc analysis revealed that all significant findings were produced by differences among children who were not exposed to secondhand smoke. Furthermore, among children not exposed to smoke, those in the school-based care group vs the usual-care group had more symptom-free days overall (11.5 vs 10.5;P= .046), had fewer days needing rescue medications (1.6 vs 2.3;P= .03), and were less likely to have had 3 or more acute visits for asthma (6 [13%] of 47 children vs 17 [31%] of 54 children;P= .03). Conclusions School-based provision of inhaled corticosteroids significantly improved symptoms, quality of life, and absenteeism among urban children with mild persistent to severe persistent asthma. This effect was seen only among children not exposed to secondhand smoke.

Drs Derauf and Derauf make an important point. The reduction of missed immunization opportunities is a very cost-effective way to deal with low vaccination rates in our cities, and the portable record might overcome one of the major obstacles to using immunization opportunities, namely, lack of immunization status information at the medical encounter. As suggested, the effectiveness of the portable record might be vastly improved by making it more attractive through use of baby pictures. Complimentary ideas include the use of reminder stickers on these cards for the next appointment and expanding the cards into "baby passports" that include developmental data and other screening information.

Asthma Admission Threshold has Risen to Maintain Stable Hospitalization Rates Despite Increasing Severity • 542

A historical cohort study was performed in order to assess the hypothesis that even mild bronchiolitis in infancy is a predictor of wheezing later in childhood. Subjects who had experienced bronchiolitis and a matched control group were compared in terms of reported wheezing 8 years later. A highly significant difference was found between the bronchiolitis group and the control group in terms of current wheezing (P < .0001, relative risk 3.24). This difference was maintained after adjusting for many potentially confounding variables including family history of allergy and other allergic manifestations in the child. Results suggested that 13.6% of a normal practice population in the age range 6 to 9 years currently wheeze, but that 44.1% of children who experienced bronchiolitis currently wheeze. Based on the incidence of bronchiolitis (4.27/100 children in their first 2 years of life) and the relative odds for wheezing derived from a logistic regression model including variables that measured passive smoking, genetic tendency to wheeze, and bronchiolitis, calculations of attributable risk suggested that wheezing in 9.4% of the population of children who currently wheeze was attributable to bronchiolitis.

The possibility that controllable environmental factors such as passive smoking and non-breast feeding contribute substantially to wheezing has implications for prevention. Effects of passive smoking and non-breast feeding on wheezing in children aged 6 to 10 years were explored in a historical cohort study of 223 children. Family history of respiratory allergy or asthma, male sex, maternal smoking, and non-breast feeding were significantly associated (p less than 0.05) with wheezing in bivariate analysis. In multivariate loglinear analyses, predictors of wheezing included non-breast feeding (p = 0.05, odds ration = 2.1), male sex (p less than 0.03, odds ratio = 3.1), and family history of respiratory allergy (p less than 0.03, odds ratio = 2.6). In a second model, predictors included an interaction of maternal smoking and family history (p less than 0.005, odds ratio = 4.6) in addition to male sex and family history of respiratory allergy. In further exploration based on tabular analysis, maternal smoking appeared to increase wheezing among children in whom the family history of respiratory allergy was positive (p less than 0.001). Among children in whom the family history of respiratory allergy was negative, non-breast feeding appeared to increase wheezing (p = 0.01). Promotion of breast feeding and reduction of maternal smoking might reduce childhood wheezing.

Concern about the long-term sequelae of bronchiolitis has been raised through studies of children hospitalized for bronchiolitis, but the long-term sequelae of mild bronchiolitis have not been studied. We assessed the hypothesis that 25 children with mild bronchiolitis (index subjects) were at greater risk for abnormalities of pulmonary function or airway reactivity to cold air between the ages of 8 and 12 years than were randomly selected, matched controls. There were no consistent differences in pulmonary function or airway reactivity between index and control groups. Airway hyperreactivity was found in five control subjects and three index subjects, and all children with symptomatic asthma were identified by cold air challenge. Our data suggest that children with a history of mild bronchiolitis are not at increased risk between ages 8 and 12 years for airway hyperreactivity or for abnormalities in pulmonary function.

A group of 153 children (51 with a history of bronchiolitis and 102 matched controls) were evaluated in a historical cohort study at a mean age of 8 years and again at 13 years to test the primary hypothesis that mild bronchiolitis, far more common than severe (hospitalized) bronchiolitis, predicts wheezing. A secondary hypothesis was that passive smoking also predicts wheezing. Many potentially confounding variables such as family history of asthma were controlled in analyses. Analysis at 13 years produced results that were not anticipated from previous analysis of interviews at age 8. Although mild bronchiolitis was a powerful predictor of wheezing at age 8 years, it was no longer a strong predictor of wheezing at age 13 in either bivariate or multivariate analysis. Although epidemiologic studies, by their nature, cannot prove causality, findings are consistent with the hypothesis that sequelae often follow mild bronchiolitis but diminish during childhood. Maternal smoking was a powerful predictor of wheezing at age 13 in bivariate analysis (Kendall's Tau B = 0.19, P less than 0.01) and in multivariate analysis (odds ratio = 2.67, P less than 0.01). In children at highest risk for wheezing, males with a family history of asthma, multivariate analysis suggested that maternal smoking is associated with an increase in wheezing from 36% to 60%. We conclude that passive smoking, previously identified as a risk factor in this population for both bronchiolitis in infancy and wheezing at age 8, is a risk factor for wheezing-associated morbidity throughout the childhood years.

The epidemiologic patterns and the economic impact of acute lower respiratory tract illness (LRTI) in children under age two were studied using data collected from November 1, 1971-August 30, 1975 in a suburban pediatric practice in Monroe County, New York. LRTI was responsible for 23 illness episodes per 100 child-years among children in their first two years of life. This indicates that a cohort of 100 children might be anticipated to have 46 LRTI episodes from birth until their second birthday. The majority of episodes correlated with the presence of four viruses in the community, most commonly respiratory syncytial virus. The minimal, estimated direct cost of LRTI in the first two years of life based on 1984 cost data was equivalent to $35.14 for every child and was comprised of hospitalization cost ($19.68) and ambulatory care cost ($15.46). Hospitalization costs attributable to LRTI comprised at least 2.5 per cent of all hospitalization costs in this age group. Immunization against the four most common respiratory viruses, at a reasonable cost per child immunized, would appear to be cost beneficial.

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, 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 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 pregnancyinduced hypertension, childhood injuries, and subsequent pregnancies among low-income women with no previous live births.

Bronchiolitis is a common lower respiratory tract illness in infants and has substantial acute morbidity and sequelae. To identify risk factors for bronchiolitis, a case-control study was conducted in which 53 subjects who had bronchiolitis were matched with two controls who had no bronchiolitis in infancy. In multivariate analysis, direct effects of passive smoking and older siblings achieved statistical significance. Family history of asthma appeared to interact with older siblings. Among subjects without a family history of asthma, statistically significant predictors proved to be older siblings (odds ratio, 2.31) and passive smoking (odds ratio, 3.87). Among subjects with a family history of asthma, older siblings proved to be an even stronger predictor (odds ratio, 46.81), while the odds ratio for passive smoking did not change much (odds ratio, 4.03). The combined presence of older siblings and passive smoking yielded an odds ratio of 8.94 among subjects without a family history of asthma and 181.67 among subjects with a family history of asthma. Analysis provided risk estimates that were particularly high for certain groups. Among infants with a family history of asthma, 49% who have an older sibling may develop bronchiolitis. If they are also exposed to cigarette smoke, almost 80% may develop bronchiolitis. Among infants without a family history of asthma, bronchiolitis may develop in 46% of infants if there is both an older sibling and exposure to smoke. Exposure of infants to cigarette smoke might diminish more rapidly if clinicians and parents were aware of such high risks. Efforts to reduce morbidity from bronchiolitis in infants might best be directed at the reduction of smoking in families with previous children, particularly if there is a family history of asthma, and at methods that protect infants from respiratory virus carried by siblings.

• A historical cohort study was conducted to measure lower respiratory tract illness (LRTI) up to nine years following mild bronchiolitis and to discover attributes that predict an increased risk for LRTI in childhood. The hypothesis assessed was that the occurrence of bronchiolitis predicts LRTI following the second birthday (childhood LRTI) after adjusting for potentially confounding variables such as a family history of respiratory allergy. Fifty-three children (index subjects) who were seen for bronchiolitis at a suburban community pediatric practice were compared on the basis of childhood LRTI with a control group of 159 children. Chart review, when children were a mean of 8 years old, determined the frequency of childhood LRTI. The mean frequency of childhood LRTI was greater in index subjects than in control subjects (1.62 vs 0.98). This difference remained after adjusting for potentially confounding variables. The yearly occurrence of any LRTI was significantly more common in index subjects through the third year of life (38% vs 15%). A tendency for a more common occurrence of any LRTI was noted through the fifth year (25% vs 16%), but not thereafter. Further analysis of index subjects disclosed that only those who experienced a subsequent LRTI before the second birthday were at an increased risk for the development of childhood LRTI. ( AJDC 1985;139:625-631)

The etymology of bronchiolitis suggests specific histologic findings, and formal recognition of this meaning has been given (American College of Chest Physicians—American Thoracic Society Joint Committee, 1975). Yet, in practice, this label is applied on the basis of clinical findings alone, and diagnostic criteria vary widely. Cardinal among these findings is wheezing, which is a clinical sign associated not with unique, but with various histologic changes. Use of one term to describe both a specific histopathologic entity and a loosely defined clinical syndrome invites obfuscation. In the case of bronchiolitis, it may contribute to the controversy that surrounds this syndrome. I attempt to highlight controversies in the use of this term, to identify their origins, and to suggest principles on which they may be resolved. In selected areas, a resolution is suggested. According to one observer (McIntosh 1 ): Clinicians who care for small children all know what [bronchiolitis] means: an