Geographic Hotspots for Low Birthweight: An Analysis of Counties With Persistently High Rates.

This study evaluated persistency in county-level rates of low birthweight outcomes to identify "hotspot counties" and their associated area-level characteristics. Administrative data from the National Center for Health Statistics Birth Data Files, years 2011 to 2016 were used to calculate annual county-level rates of low birthweight. Counties ranking in the worst quintile (Q5) for ≥3 years with a neighboring county in the worst quintile were identified as hotspot counties. Multivariate logistic regression was used to associate county-level characteristics with hotspot designation. Adverse birth outcomes were persistent in poor performing counties, with 52% of counties in Q5 for low birthweight in 2011 remaining in Q5 in 2016. The rate of low birthweight among low birthweight hotspot counties (n = 495) was 1.6 times the rate of low birthweight among non-hotspot counties (9.3% vs 5.8%). The rate of very low birthweight among very low birthweight hotspot counties (n = 387) was twice as high compared to non-hotspot counties (1.8% vs 0.9%). A one standard deviation (6.5%) increase in the percentage of adults with at least a high school degree decreased the probability of low birthweight hotspot designation by 1.7 percentage points (P = .006). A one standard deviation (20%) increase in the percentage of the population that was of minority race/ethnicity increased hotspot designation for low birthweight by 5.7 percentage points (P < .001). Given the association between low birthweight and chronic conditions, hotspot counties should be a focus for policy makers in order to improve health equity across the life course.

Trends in hospital discharge disposition for elderly patients with infective endocarditis: 1993 to 2003.

OBJECTIVES: To examine hospital discharges of elderly patients hospitalized with infective endocarditis (IE). DESIGN: A retrospective analysis of hospital discharges from 1993 to 2003. SETTING: The Nationwide Inpatient Sample (NIS), which approximates a 20% sample of all U.S. acute care hospitals. PARTICIPANTS: All patients aged 65 and older with a primary or secondary International Classification of Diseases, Ninth Revision, diagnosis code for IE were included. MEASUREMENTS: The main outcome measures were in-hospital mortality and, for survivors, discharge disposition: to home (with home health care) or to a facility. RESULTS: Hospitalizations for IE increased 26.0% over the 10-year period, from 3.19 per 10,000 elderly patients in 1993 to 3.95 per 10,000 in 2003. Over the study period, a trend toward increasing discharge to nursing home and decreasing discharge to home and home health care was evident. Discharge to home for survivors decreased from 57.7% to 35.0% over the study period, whereas discharge to nursing facilities increased from 27.7% to 44.3%. Over the 10-year study period, elderly patients hospitalized with IE were 2.3 times as likely to be discharged to a facility as to home. CONCLUSION: Hospital discharge dispositions have changed for elderly patients admitted with IE. Changes in the patient's age, severity of illness, or comorbidities do not explain these trends. Financial incentives are the most likely factor influencing the substitution in discharge dispositions for elderly patients with IE.

Labor market productivity costs for caregivers of children with spina bifida: a population-based analysis.

BACKGROUND: Caregiver productivity costs are an important component of the overall cost of care for individuals with birth defects and developmental disabilities, yet few studies provide estimates for use in economic evaluations. OBJECTIVE: This study estimates labor market productivity costs for caregivers of children and adolescents with spina bifida. METHODS: Case families were recruited from a state birth defects registry in Arkansas. Primary caregivers of children with spina bifida (N = 98) reported their employment status in the past year and demographic characteristics. Controls were abstracted from the Current Population Survey covering the state of Arkansas for the same time period (N = 416). Estimates from regression analyses of labor market outcomes were used to calculate differences in hours worked per week and lifetime costs. RESULTS: Caregivers of children with spina bifida worked an annual average of 7.5 to 11.3 hours less per week depending on the disability severity. Differences in work hours by caregivers of children with spina bifida translated into lifetime costs of $133,755 in 2002 dollars using a 3% discount rate and an age- and sex-adjusted earnings profile. Including caregivers' labor market productivity costs in prevention effectiveness estimates raises the net cost savings per averted case of spina bifida by 48% over the medical care costs alone. CONCLUSIONS: Information on labor market productivity costs for caregivers can be used to better inform economic evaluations of prevention and treatment strategies for spina bifida. Cost-effectiveness calculations that omit caregiver productivity costs substantially overstate the net costs of the intervention and underestimate societal value.

Trends in hospitalizations associated with pediatric traumatic brain injuries.

OBJECTIVES: The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons. METHODS: Analysis of existing data (1991-2005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratified according to age, gender, severity of traumatic brain injury, and outcome, were determined. RESULTS: From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100,000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100,000 in 1991-1993 to 2.8 deaths per 100,000 in 2003-2005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged. CONCLUSIONS: Although pediatric hospitalization rates for mild traumatic brain injuries have decreased over the past 15 years, rates for moderate and severe traumatic brain injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.

Health state preference scores for children with permanent childhood hearing loss: a comparative analysis of the QWB and HUI3.

PURPOSE: The aim of this study was to compare two preference-weighted, caregiver-reported measures of health-related quality of life for children with permanent childhood hearing loss to determine whether cost-effectiveness analysis applied to deaf and hard of hearing populations will provide similar answers based on the choice of instrument. METHODS: Caregivers of 103 children in Arkansas, USA, with documented hearing loss completed the Quality of Well-Being Scale (QWB) and the Health Utilities Index Mark 3 (HUI3) to describe the health status of their children. Audiology and other clinical measures were abstracted from medical records. Mean scores were compared overall and by degree of hearing loss. Linear regression was used to correlate preference scores with a four-frequency pure-tone average, cochlear implant status, and other factors. RESULTS: Mean preference scores for the QWB and HUI3 were similar (0.601 and 0.619, respectively) although the HUI3 demonstrated a wider range of values (-0.132 to 1.000) compared to the QWB (0.345-0.854) and was more sensitive to mild hearing loss. Both measures correlated with the pure-tone average, were negatively associated with comorbid conditions and positively associated with cochlear implant status. In the best fitting regression models, similar estimates for cochlear implant status and comorbid conditions were obtained from the two measures. CONCLUSIONS: Despite considerable differences in the HUI3 and the QWB scale, we found agreement between the two instruments at the mean, but clinically important differences across a number of measures. The two instruments are likely to yield different estimates of cost-effectiveness ratios, especially for interventions involving mild to moderate hearing loss.

Measuring the cost-effectiveness of technologic change in the treatment of pediatric traumatic brain injury.

Substantial variation exists with respect to the management of traumatic brain injuries (TBI) in children. Centers that practice aggressive treatment of TBI may improve survival, but it is not clear that the outcomes can be justified using cost-effectiveness criteria. This study illustrates the use of cost-effectiveness analysis to assess interventions for improving outcomes in children by assessing the cost per quality-adjusted life year (QALY) gained from technological change in the treatment of TBI. Cost and survival data associated with technological change in the treatment of pediatric TBI was based on nationally representative hospital administrative data for all children <21 years with a TBI who required endotracheal intubation or mechanical ventilation. With QALYs of pediatric TBI survivors based on life expectancies ranging between 5 and 30 years and on an estimated preference score of approximately 0.5, the estimated incremental cost-effectiveness ratio ranges between $19,000 and $109,000 per QALY gained. Adding estimated rehabilitation costs increases the cost-effectiveness ratio to between $57,000 and $244,000 per QALY. Sensitivity analysis indicates that estimates of life years gained are critical to the estimated ratio. If TBI survivors live more than 5 years, then the estimated cost-effectiveness ratio seems favorable.

Congenital defects among liveborn infants with Down syndrome.

BACKGROUND: Many infants with Down syndrome (DS) have co-occurring congenital malformations requiring intensive surgical and medical management. To anticipate the care needed by these infants, providers and parents require accurate information about birth defects that may be present. This article uses a unique national hospital discharge dataset to identify the rate at which structural birth defects are identified among liveborn infants with DS. METHODS: ICD-9-CM diagnosis codes for data from the Healthcare Cost and Utilization Project were used to identify infants with and without DS, and to classify birth defects. The study population consisted of liveborn infants discharged from the hospital from 1993 through 2002. ORs for the association between the occurrence of congenital malformations and the presence of DS were computed using logistic regression models for survey data. RESULTS: Discharge data included 11,372 DS and 7,884,209 non-DS births, representing national estimates of 43,463 DS and 39,716,469 non-DS births respectively. In addition to congenital heart defects that co-occurred most often in DS infants compared to infants without DS, the risks for gastrointestinal malformations (OR 67.07), genitourinary malformations (OR 3.62), orofacial malformations (OR 5.63), and abdominal wall malformations (OR 3.25) were also elevated in infants with DS. There was no difference in the risk of spina bifida between infants with and without DS. CONCLUSIONS: This is the first nationally representative compilation of the co-occurrence of congenital malformations associated with DS. This information may assist providers and parents in their attempts to understand and prepare for the true burden of this condition.

Child health-related quality of life following neurocritical care for traumatic brain injury: an analysis of preference-weighted outcomes.

BACKGROUND: Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking. OBJECTIVE: This study seeks to describe the preference-weighted health outcomes of children following a traumatic brain injury at 3- and 6-months following pediatric intensive care unit (ICU) discharge. SETTING/PATIENTS: Children aged 5-17 who required ICU admission and endotracheal intubation or mechanical ventilation. MAIN OUTCOME MEASURES: The Quality of Well-being (QWB) score was used to describe preference-weighted outcomes. Clinical measures from the intensive care unit stay were used to estimate risk of mortality. Risk of mortality, Glasgow coma scores, patient length of stay in the intensive care unit, and parent-reported items from the Child Health Questionnaire (CHQ) were used to test construct validity. METHODS: Subject data were obtained from nine pediatric intensive care units with consent procedures approved by representative institutional review boards. Medical records containing clinical information from the ICU stay were abstracted by the study coordinating center. Caregivers of children were contacted by telephone for follow-up interviews at 3- and 6-months following ICU discharge. All interviews were conducted by telephone with the primary caregiver of the injured child. Preference score statistics are presented overall and in relation to characteristics of the patient and their ICU admission. RESULTS: A response rate of 59% was achieved for the 3-month interviews (N = 56) and 67% for the 6-month interviews (N = 65) for caregivers of children aged 5 years and above that consented to participate. Overall, QWB scores averaged 0.508 (95% CI: 0.454-0.562) at the 3-month interview and 0.582 (95% CI: 0.526-0.639) at the 6-month interview. For both interview periods, scores ranged from 0.093 to 1.0 on a 0-1 value scale, where 0 represents death and 1 represents perfect health. Specific acute and chronic health problems from the QWB scale were present more often in patients with higher injury severity. Mortality risk, ICU length of stay, Glasgow Coma Scales, and parental reported summary scores from the CHQ all correlated correctly with the QWB scores. CONCLUSIONS: The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.

Reduction in newborns with discharge coding of in utero alcohol effects in the United States, 1993 to 2002.

OBJECTIVE: To determine whether use of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for fetal alcohol effects has declined during the past 10 years among hospitalized newborns in the United States. DESIGN: Trends in use of the ICD-9-CM code 760.71, "alcohol affecting the fetus," among newborns from 1993 through 2002 were compared with trends in self-reported drinking during pregnancy and maternal diagnoses of alcohol abuse during childbirth. SETTING: Sampled short-term, nonfederal general and specialty hospitals. PARTICIPANTS: Infants born from 1993 to 2002 in the United States who were included in the Healthcare Cost and Utilization Project databases. MAIN OUTCOME MEASURES: Documentation of ICD-9-CM code 760.71 among newborns, self-reported drinking during pregnancy, and diagnoses of maternal alcohol abuse during childbirth from 1993 through 2002. RESULTS: The prevalence of the ICD-9-CM code 760.71 for alcohol affecting the fetus, as documented in the discharge record of newborns, declined from 0.73 (95% confidence interval, 0.56-0.92) per 1000 live births in 1993 to 0.17 (95% confidence interval, 0.13-0.20) per 1000 live births in 2002. Rates declined concurrently with those of self-reported alcohol consumption during pregnancy and diagnoses of maternal alcohol abuse during childbirth. CONCLUSIONS: Use of the ICD-9-CM code for alcohol affecting the fetus among newborns declined 75% throughout 10 years. Results may be due to decreases in drinking during pregnancy, decreases in disclosure of alcohol use by the mother, or more selective use of the discharge code. National hospital discharge databases may allow cost-effective monitoring of public health interventions that address rare conditions of the fetus and newborn.

National rates of birth defects among hospitalized newborns.

BACKGROUND: The Healthcare Cost and Utilization Project (HCUP) family of hospital discharge databases offer an unprecedented opportunity to generate national estimates of newborn infants with birth defects. This report estimates national hospital admissions for newborn infants diagnosed with birth defects computed from HCUP and compares them to pooled prevalence figures computed from state birth defect surveillance systems. METHODS: HCUP-derived rates of 36 birth defects from 1997 through 2001 were compared to rates derived from pooled data reported by 26 state-based surveillance systems stratified by inclusion of elective terminations in case definitions. Rate ratios (RRs) were calculated for each birth defect by dividing the rate derived from HCUP by the rate derived from the relevant surveillance systems. RESULTS: HCUP newborn hospitalization rates for birth defects closely approximate pooled birth defect rates for surveillance systems that do not include elective terminations. HCUP rates were not significantly different for 35 of 36 defects. Overall, 20 HCUP rates were within 10% of state rates, 11 more were within 20% of state rates, and only 1 differed by more than 50%. HCUP rates compared most closely to state rates for cardiovascular (VSD RR = 0.98, ASD = 0.96, pulmonary valve atresia and stenosis = 0.92), orofacial (cleft palate RR = 1.10, cleft lip = 1.06), and genitourinary defects (obstructive genitourinary RR = 1.01, bladder exstrophy = 0.97). HCUP rates compared less favorably to rates derived from surveillance systems that included elective terminations. CONCLUSIONS: HCUP data approximate state-based surveillance system data for defects that are easily recognized in the newborn period and infrequently a cause for elective termination. HCUP data can be used to examine the impact of public health efforts on the number of infants born with birth defects as well as the cost and consequences of variations in the hospital management of birth defects.

Hospitalizations of newborns with folate-sensitive birth defects before and after fortification of foods with folic acid.

CONTEXT: The prevalence of neural tube defects is reduced in populations of women who receive folic acid supplementation. Since 1998, grain products in the United States have been fortified with folic acid. Fortification may have additional benefits by reducing the national prevalence of newborn hospitalizations for other folate-sensitive birth defects. OBJECTIVE: Our purpose with this work was to compare rates of hospitalizations of newborns with folate-sensitive birth defects before and after implementation of fortification of grains. METHOD: National hospital discharge data from the Healthcare Cost and Utilization Project were used to compute rates of newborn hospitalizations for selected birth defects per 10,000 live births in the United States. Newborn hospitalization rates involving congenital anomalies recognizable at birth were analyzed for 5 years before fortification of grains and 5 years after fortification. Additional analyses compared changes in newborn hospitalization rates for birth defects by race/ethnicity, income, insurance status, and region of the country. RESULTS: Newborn hospitalization rates for spina bifida decreased 21% from 1993-1997 to 1998-2002. Newborn hospitalization rates also decreased for anencephaly (20%) and limb-reduction defects (4%). Decline in hospitalizations for spina bifida occurred more often among Hispanic newborns (33%) than among white (13%) or black (21%) newborns. Decline in limb-reduction defects was seen primarily among blacks (11%). Findings using hospitalization data were similar to recent reports using birth defect surveillance systems with the exception of findings for orofacial clefts and conotruncal heart defects. No reductions were noted in newborn hospitalizations for these anomalies. CONCLUSIONS: Results from this ecological study fail to demonstrate substantial declines in newborn hospitalizations beyond those anticipated from a reduction in neural tube defects. The society-wide impact of the fortification program on birth defects and other health conditions should continue to be monitored.

Congenital malformations among liveborn infants with trisomies 18 and 13.

Trisomy 18 and trisomy 13 are associated with serious and/or fatal birth defects, with death frequently occurring in the first month of life. Previous studies are limited by small samples and are dated. This study characterized the comorbid birth defects associated with trisomy 18 and trisomy 13 among US liveborn infants using the Healthcare Cost and Utilization Project's Kids' Inpatient Database and Nationwide Inpatient Sample, two large, current and nationally representative databases. The occurrence of 39 commonly reported comorbid birth defects among infants with trisomies 18 and 13 was compared to the occurrence of malformations among newborns without trisomies. The prevalences of trisomy 18 and 13 were 1.29/10,000 and 0.85/10,000 live births, respectively. Among infants with trisomy 18, 61% were female, 45.4% with heart defects. Among those with trisomy 13, 53% were female, 38.4% had heart defects, 24.5% had orofacial anomalies, and 11.2% had central nervous system abnormalities. More than half of the newborns with both conditions died prior to discharge. This updated information can be used to inform clinical decision-making and may help providers better prepare families for infants with trisomies.

Variation in the use of intracranial-pressure monitoring and mortality in critically ill children with meningitis in the United States.

OBJECTIVE: Our goal was to describe patient and hospital characteristics associated with the use of intracranial pressure monitors and outcomes in critically ill children with meningitis. METHODS: This was a retrospective cohort study of children 0 to 17 years of age hospitalized with meningitis and requiring mechanical ventilation using the 1997 and 2000 Kids' Inpatient Database. We generated national estimates of rates of intracranial pressure monitoring and in-hospital mortality by patient and hospital characteristics, and compared in-hospital mortality, hospital length of stay, and total charges for children who received an intracranial pressure monitor with those who did not. RESULTS: There were an estimated 1067 and 1170 hospitalizations nationally for childhood meningitis requiring mechanical ventilation in 1997 and 2000, respectively. Most (79%) of the hospitalizations involved infants. Overall, intracranial-pressure monitors were used in 7% of hospitalizations for meningitis, with the highest rates in children aged 5 to 17 years and lowest rates in children <1 year. In-hospital mortality was 19.6%, highest in children aged 5 to 17 years and in children with pneumococcal infections. In multivariate regression analyses, intracranial pressure monitor use was positively associated with age, patient volume, and hospitals located in the West census region. In-hospital mortality was associated with increasing age, hospitalization in the year 2000, self-pay/other insurance status, and pneumococcal meningitis. There was no difference in hospital mortality associated with use of intracranial pressure monitors, but both length of stay and log-transformed total hospital charges were significantly higher in the group that received an intracranial-pressure monitor. CONCLUSION: Intracranial pressure monitoring for the treatment of critically ill children with meningitis varies by census region, the number of cases treated, and patient age. The use of intracranial pressure monitoring was not statistically associated with mortality in this national sample.

Variation in pediatric intensive care therapies and outcomes by race, gender, and insurance status.

CONTEXT: The differential allocation of medical resources to adult patients according to characteristics such as race, gender, and insurance status raises the serious concern that such issues apply to critically ill children as well. OBJECTIVE: This study examined whether medical resources and outcomes for children admitted to pediatric intensive care units differed according to race, gender, or insurance status. DESIGN: An observational analysis was conducted with use of prospectively collected data from a multicenter cohort. Data were collected on 5,749 consecutive admissions for children from three pediatric intensive care units located in large urban children's hospitals. PARTICIPANTS: Children aged

Attenuation of racial differences in health service utilization patterns for previously uninsured children in the Delta.

CONTEXT: A school-based health insurance program for children of the working poor was conducted in 2 isolated, rural communities in the Lower Mississippi Delta region. The larger of the 2 communities had an array of locally available health care providers, whereas the smaller community did not. In response to this lack of available care, the project designed and delivered outreach programs, including transportation to providers. PURPOSE: The purpose of this paper is to examine the role of race, age, and gender in the relationships between the utilization of care and the impact of outreach programs. METHOD: General estimating equation models are used to examine the response of utilization variables to race, age, gender, and community. Four years of insurance claims data are analyzed. FINDINGS: Race is seen to be an important component of utilization. The majority of participants were African American; however, children receiving prescription services, emergency room care, routine physician visits, and hospital outpatient services were more likely to be white. Outreach programs in vision and dental services were found to eliminate racial differences and increase utilization. A relatively strong gender effect was found in prescription, wellness, vision, and dental services. CONCLUSIONS: Previous research has shown differences by race in utilization of care. Our findings show that targeted outreach programs can significantly diminish these differences. Findings also suggest that barriers to health care for poor rural children are closely linked to transportation and availability of providers, not merely to cost of care or insurance.

Hospitalizations for critically ill children with traumatic brain injuries: a longitudinal analysis.

OBJECTIVE: This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988-1999 to describe the benefits of improved treatment. DESIGN: Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals. SETTING: Hospital inpatient stays from all types of U.S. community hospitals. PARTICIPANTS: The study sample included all children aged 0-21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately dollar 17 billion, whereas acute care hospitalization costs increased by dollar 1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a dollar 3.76 billion loss in economic benefits. CONCLUSIONS: More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.

Health state preference scores of children with spina bifida and their caregivers.

Cost-effectiveness evaluations of interventions to prevent or treat spina bifida require quality of life information measured as preference scores. Preference scores of caregivers also may be relevant. This study tested whether the preference scores of children with spina bifida and their caregivers would decrease as disability in the child increased. Families of children aged 0-17 with spina bifida (N = 98) were identified using a birth defect surveillance system in the state of Arkansas. Primary caregivers of children with spina bifida identified other families with an unaffected child (N = 49). Preference scores for child health states were determined using the Health Utilities Index--Mark 2 (HUI2). Caregiver preference scores were determined using the Quality of Well-Being (QWB) scale. Children with spina bifida were categorized into three disability levels according to the location of the child's lesion. Mean preference scores declined for both affected children and the primary caregiver as disability in the child increased. In multivariate analysis, the preference score of the child was a significant and positive predictor of the primary caregiver's preference score. A more modest association was found for caregiver health preference scores by lesion location. The findings can inform cost-effectiveness evaluations of interventions to treat or prevent spina bifida.

National hospitalization impact of pediatric all-terrain vehicle injuries.

OBJECTIVE: All-terrain vehicle (ATV) injuries among children represent a significant and growing problem. Although state-level analyses have characterized some aspects of pediatric ATV-related injuries, little information on the national impact on hospitalization is available. This study was designed to characterize more fully the patterns of injury, hospital length of stay, and hospital charges associated with ATV-related injuries, with a nationally representative sample. METHODS: Analyses were based on the 1997 and 2000 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The KID is the only national, all-payer database of hospital discharges for children. KID data were weighted to represent all discharges from general hospitals in the United States. Discharges with external cause-of-injury codes consistent with off-road ATV-related injuries were selected, and the affected population was described. Nationally representative rates of ATV-related injuries were calculated, and changes between 1997 and 2000 were documented. RESULTS: An estimated 5292 children were hospitalized because of ATV-related injuries during the 2-year period, and hospitalizations increased 79.1% between 1997 and 2000. Rates of ATV-related hospitalization were highest among adolescent white male subjects, consistent with previous studies. Most patients had hospital lengths of stay of <4 days (68%), but 10% had stays of >8 days. Injury severity varied considerably, with more than one third of patients sustaining moderate to severe injuries. Approximately 1% of hospitalizations resulted in in-hospital deaths. Total hospital charges for this injury mechanism were 74367677 dollars for the 2-year study period. Most of these charges were paid by private insurers. CONCLUSIONS: This study provides evidence supporting recent substantial increases in childhood ATV-related injuries. The hospitalization impact of ATV-related injuries among children is considerable. Our data support the need for ongoing creative attempts to identify effective strategies to decrease ATV injuries among children.

Characteristics of children with asthma who are enrolled in a Head Start program.

BACKGROUND: Asthma is an increasing public health concern that disproportionally affects children. In 1998, the Centers for Disease Control identified children aged 0 to 4 years as the "driving force" behind climbing rates of asthma-related emergency department visits and hospitalizations. Despite the significant asthma burden in preschool children, few studies characterize this population. OBJECTIVE: This study identifies and characterizes children at risk for asthma who are enrolled in a local Head Start program. METHODS: Caregivers of 368 children aged 3 to 5 years who were identified by using an asthma survey were recruited. Data were collected on demographics, health care use and access, medication use, symptoms, and trigger exposure. Exposure to tobacco smoke was determined by urinary cotinine and allergen sensitization by skin prick test. RESULTS: At baseline, 64% of the children had more than 1 emergency department visit for asthma in their lifetime, whereas 31% had more than 1 visit in the previous 6 months. Caretakers reported smoking in 37% of households with cotinine exceeding 20 ng/mg in 27% of the sample. Twenty-one percent reported symptoms consistent with intermittent asthma, and 79% reported symptoms consistent with persistent asthma. Forty-five percent of the children reported nighttime symptoms more than 1 night per week. Seventy-one percent had positive test results for more than 1 allergen, and 42% had positive test results for more than 3 allergens. Only 32% of children with persistent asthma had both rescue and controller medications. CONCLUSION: Children with asthma enrolled in a Head Start program have significant environmental tobacco smoke exposure, are highly atopic and symptomatic, and do not receive appropriate medication treatment. Overall, children in the study had poor asthma control. This high-risk group could benefit from case management programs.

Hospital survival of very-low-birth-weight neonates from 1977 to 2000.

OBJECTIVE: To determine patterns of survival for very low birth weight (VLBW, birth weight 501 to 1500 g) neonates over 23 years. STUDY DESIGN: Data for 4873 VLBW neonates born from 1977 to 2000 were divided into five epochs. The primary outcome was survival to hospital discharge. Birth weight-specific survival rates were estimated by race and gender for each epoch. Presence of comorbidities and congenital anomalies, delivery mode, and provision of artificial ventilation were investigated to determine whether they could explain observed survival patterns. RESULTS: From 1977 to 1995, survival increased from 50.2% to 81.0% as the proportion of VLBW neonates receiving artificial ventilation rose from 59.0% to 80.9%. Survival was unchanged between 1990 to 1995 and 1996 to 2000. Black females maintained a survival advantage over the entire study period. Survival improved for neonates with congenital anomalies over time, but had little impact on race/gender survival patterns. Survival patterns also could not be explained by comorbidity status, delivery mode, or access to artificial ventilation. CONCLUSION: The survival advantage of VLBW black females persists and remains unexplained.