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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.To estimate the incidence of clinical deterioration leading to intensive care unit transfer in previously healthy infants with respiratory syncytial virus (RSV) infection hospitalized on a general pediatric unit and, to assess the hypothesis that history, physical examination, oximetry, and chest radiographic findings at time of presentation can accurately identify these infants.Study Design.A virology database was used to identify and determine the disposition of all children ≤1 year of age admitted to the Children's Hospital at Strong (CHaS) with RSV infection during the 1985 to 1994 respiratory seasons. Index patients were all previously healthy, full-term infants admitted initially to the general inpatient services at CHaS or Rochester General Hospital, a second University of Rochester teaching hospital, whose clinical deterioration led to transfer to the pediatric intensive care unit (PICU). These infants were matched retrospectively (for year and date of infection, sex, chronologic age, and race) with two hospitalized controls who did not require PICU transfer. Chest radiographic findings, respiratory rate (RR), O2 saturation, and presence of wheezing at time of presentation to the emergency department (ED) were compared.Results.During the study years, 542 previously healthy, full-term infants were admitted to the general pediatric unit at CHaS with proven RSV infection. Ten (1.8%; 95% confidence interval, 0.9%, 3.4%) were transferred subsequently to the PICU, primarily for close monitoring of progressive respiratory distress. Data for these patients and 7 patients transferred from Rochester General Hospital to the PICU at the CHaS were compared with those for control patients. The mean RR in the ED (63 vs 50), and O2 saturation in the ED (88% vs 93%) were modestly abnormal in cases compared with controls. Wheezing on examination at time of presentation and chest radiographic findings did not differ between the two groups. A RR >80 and an O2saturation 97% for predicting subsequent deterioration. Each parameter, however, had a sensitivity ≤30%.Conclusion.Clinical deterioration requiring PICU admission is an uncommon occurrence in previously healthy infants admitted to a general pediatric inpatient unit with RSV infection. Extreme tachypnea and hypoxemia were both associated with subsequent deterioration; however, only a small proportion of patients who clinically deteriorated presented in this way. The clinical usefulness of these parameters, therefore, is limited. respiratory syncytial virus, deterioration, healthy infants, prediction.

The purpose of this randomized clinical study was to test the efficacy of a resiliency training approach for people with diabetes who have previously received standard diabetes self-education.A single-blinded, randomized design was employed with repeated measures (baseline, 3 months, 6 months) with 67 participants assigned to either treatment as usual (n = 37) or the resiliency classes (n = 30). Outcome variables included physiological measures (glycosylated hemoglobin, waist measurement, eating and exercise habits) and psychosocial measures (self-efficacy, locus of control, social support, and purpose in life).Analyses of variance indicated that the intervention group had higher levels of resiliency as reported by knowing positive ways of coping with diabetes-related stress, knowing enough about themselves to make right diabetes choices, having fun in life, eating healthier, and increasing physical activity compared with the control group at 3 months (P < .05). Glycosylated hemoglobin and waist measurement improved but not significantly.Interventions to foster resilience among people with diabetes have the potential to make an important contribution to increasing positive life outcomes. Diabetes educators using the resiliency approach in tandem with standard diabetes education programs can assist their patients to become more self-directed in their diabetes care.

To estimate the independent contribution of birth weight to asthma prevalence among children younger than 4 years in the United States and to compare the magnitude of its effect on asthma between African American and white children.Cross-sectional analysis using the 1988 National Maternal-Infant Health Survey and 1991 Longitudinal Follow-up Survey.United States.Eight thousand seventy-one subjects, selected from a randomized, systematic population-based sample and weighted to be nationally representative, who completed both initial and longitudinal follow-up surveys and reported information on asthma diagnosis.Birth weight and other sociodemographic factors linked to birth outcome were analyzed for independent association with physician-diagnosed asthma by age 3 years.The prevalence of asthma varied by birth weight category: 6.7% in children 2500 g or more at birth, 10.9% in children 1500 to 2499 g at birth, and 21.9% in children less than 1500 g at birth (very low birth weight [VLBW]) (P.001). Some of the characteristics shown to be independently associated with asthma included: VLBW (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.3-3.6), moderately low birth weight (OR, 1.4; 95% CI, 1.1-1.8), and African American race (OR, 1.9; 95% CI, 1.6-2.4). In stratified analyses, the independent association between VLBW and asthma in white and African American populations was: OR(white), 3.1 (95% CI, 2.2-4.3) and OR(African American), 2.5 (95% CI, 2.0-3.3). The prevalence of VLBW, however, was tripled in African American compared with white children (1.8% vs 0.6%).These data confirm findings of other studies that identify a strong independent association between low birth weight and asthma. For this 1988 national birth cohort, an estimated 4000 excess asthma cases were attributable to birth weight less than 2500 g. Although the strength of the independent association between VLBW and asthma was smaller in the African American population, the substantially increased prevalence of VLBW in this community may contribute to the disproportionately increased prevalence of asthma among African American children.

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.

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.

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