Creating a health equity and inclusion office in an academic pediatric medical center: priorities addressed and lessons learned.

BACKGROUND: Over the last two decades, medical schools and academic health centers have acknowledged the persistence of health disparities in their patients and the lack of diversity in their faculty, leaders and extended workforce. We established an Office of Health Equity and Inclusion (OHEI) at our pediatric academic medical center after a thorough evaluation of prior diversity initiatives and review of faculty development data. OBJECTIVE: To describe the lessons learned at a pediatric academic medical center in prioritizing and implementing health equity, diversity and inclusion (EDI) initiatives in creating the OHEI. MATERIALS AND METHODS: We reviewed internal administrative data and faculty development data, including data related to faculty who are underrepresented in medicine, to understand the role of our EDI initiatives in the strategic priorities addressed and lessons learned in the creation of the OHEI. RESULTS: The intentional steps taken in our medical center's strategic approach in the creation of this office led to four important lessons to improve pediatric health equity: (1) board, senior executive and institutional prioritization of EDI initiatives; (2) multi-specialty and interprofessional collaboration; (3) academic approach to EDI programmatic development; and (4) intentionality with accountability in all EDI initiatives. CONCLUSION: The key lessons learned during the creation of an Office of Health Equity and Inclusion can provide guidance to other academic health centers committed to implementing institutional priorities that focus their EDI initiatives on the improvement of pediatric health equity.

Trends in Severe Pediatric Emergency Conditions in a National Cohort, 2008 to 2014.

OBJECTIVE: The objective of this study was to determine the incidence and recent trends in serious pediatric emergency conditions. METHODS: We conducted a cross-sectional study of the Nationwide Emergency Department Sample from 2008 through 2014, and included patients with age below 18 years with a serious condition, defined as each diagnosis group in the diagnosis grouping system with a severity classification system score of 5. We calculated national incidences for each serious condition using annualized weighted condition counts divided by annual United States census child population counts. We determined the highest-incidence serious conditions over the study period and calculated percentage changes between 2008 and 2014 for each serious condition using a Poisson model. RESULTS: The 2008 incidence of serious conditions across the national child population was 1721 visits per million person-years (95% confidence interval, 1485-1957). This incidence increased to 2020 visits per million person-years (95% confidence interval, 1661-2379) in 2014. The most common serious conditions were serious respiratory diseases, septicemia, and serious neurologic diseases. Anaphylaxis was the condition with the largest change, increasing by 147%, from 101 to 249 visits per million person-years. CONCLUSIONS: The most common serious condition in children presenting to United States emergency departments is serious respiratory disease. Anaphylaxis is the fastest increasing serious condition. Additional research attention to these diagnoses is warranted.

Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization.

OBJECTIVES: To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN: Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS: We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS: Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

Trends in Outpatient Antibiotic Use in 3 Health Plans.

OBJECTIVES: Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable. METHODS: Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period. RESULTS: We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased. CONCLUSIONS: These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.

Timing and Location of Emergency Department Revisits.

BACKGROUND: Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED. METHODS: We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location. RESULTS: Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36). CONCLUSIONS: Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs.

Impact of an Individual Mandate and Other Health Reforms on Dependent Coverage for Adolescents and Young Adults.

OBJECTIVE: To determine the effect of state-level dependent coverage expansion (DCE) with and without other state health reforms on exit from dependent coverage for adolescents and young adults (AYA). DATA SOURCES: Administrative longitudinal data for 131,542 privately insured AYA in Massachusetts (DCE with other reforms) versus Maine and New Hampshire (DCE without other reforms) across three periods: prereform (1/00-12/06), poststate reform (1/07-9/10), and postfederal reform (10/10-12/12). STUDY DESIGN: A difference-in-differences estimator was used to determine the rate of exit from dependent coverage, age at exit from dependent coverage, and re-uptake of dependent coverage among AYA in states with comprehensive reforms versus DCE only. PRINCIPAL FINDINGS: Implementation of DCE with other reforms was significantly associated with a 23 percent reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33 percent increase in the odds of regaining dependent coverage after a prior loss. CONCLUSIONS: Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.

Preparation for Transition to Adult Care Among Medicaid-Insured Adolescents.

BACKGROUND: Parents of children with chronic illness consistently report suboptimal preparation for transition from pediatric- to adult-focused health care. Little data are available on transition preparation for low-income youth in particular. METHODS: We conducted a mailed survey of youth with chronic illness enrolled in 2 large Medicaid health plans to determine the quality of transition preparation using the Adolescent Assessment of Preparation for Transition (ADAPT). ADAPT is a new 26-item survey designed for 16- to 17-year-old youth to report on the quality of health care transition preparation they received from medical providers. ADAPT generates composite scores (possible range: 0%-100%) in 3 domains: counseling on transition self-management, counseling on prescription medication, and transfer planning. We examined differences in ADAPT scores based on clinical and demographic characteristics. RESULTS: Among 780 and 575 respondents enrolled in the 2 health plans, respectively, scores in all domains reflected deficiencies in transition preparation. The highest scores were observed in counseling on prescription medication (57% and 58% in the 2 plans, respectively), and lower scores were seen for counseling on transition self-management (36% and 30%, respectively) and transfer planning (5% and 4%, respectively). There were no significant differences in composite scores by health plan, sex, or type of chronic health condition. CONCLUSIONS: The ADAPT survey, a novel youth-reported patient experience measure, documented substantial gaps in the quality of transition preparation for adolescents with chronic health conditions in 2 diverse Medicaid populations.

Health Care Transition in Young Adults With Type 1 Diabetes: Perspectives of Adult Endocrinologists in the U.S.

OBJECTIVE: Young adults with type 1 diabetes transitioning from pediatric to adult care are at risk for adverse outcomes. Our objective was to describe experiences, resources, and barriers reported by a national sample of adult endocrinologists receiving and caring for young adults with type 1 diabetes. RESEARCH DESIGN AND METHODS: We fielded an electronic survey to adult endocrinologists with a valid e-mail address identified through the American Medical Association Physician Masterfile. RESULTS: We received responses from 536 of 4,214 endocrinologists (response rate 13%); 418 surveys met the eligibility criteria. Respondents (57% male, 79% Caucasian) represented 47 states; 64% had been practicing >10 years and 42% worked at an academic center. Only 36% of respondents reported often/always reviewing pediatric records and 11% reported receiving summaries for transitioning young adults with type 1 diabetes, although >70% felt that these activities were important for patient care. While most respondents reported easy access to diabetes educators (94%) and dietitians (95%), fewer (42%) reported access to mental health professionals, especially in nonacademic settings. Controlling for practice setting and experience, endocrinologists without easy access to mental health professionals were more likely to report barriers to diabetes management for young adults with depression (odds ratio [OR] 5.3; 95% CI 3.4, 8.2), substance abuse (OR 3.5; 95% CI 2.2, 5.6), and eating disorders (OR 2.5; 95% CI 1.6, 3.8). CONCLUSIONS: Our findings underscore the need for enhanced information transfer between pediatric and adult providers and increased mental health referral access for young adults with diabetes post-transition.

Development and Validation of the Adolescent Assessment of Preparation for Transition: A Novel Patient Experience Measure.

PURPOSE: Significant gaps exist in health care transition (HCT) preparation that can impact care and outcomes in young adults with chronic illness. No quality measure exists to directly assess adolescent experiences of HCT preparation. Our objective was to develop an adolescent-reported measure of the quality of HCT preparation received from pediatric health care providers. METHODS: The Adolescent Assessment of Preparation for Transition (ADAPT) is a 26-item mailed survey designed for completion by 16- and 17-year-old adolescents with a chronic health condition. Adolescents from three samples (two large Medicaid insurance plans [n = 3,000 each] and one large tertiary care pediatric hospital [n = 623]) were mailed the survey. An iterative developmental process included focus groups and cognitive interviews, and validity was assessed using confirmatory factor analysis and ordinal reliability coefficients. RESULTS: Reliability and validity was evaluated for the following three prespecified composite measures: (1) counseling on transition self-management; (2) counseling on prescription medication; and (3) transfer planning. Across the three samples, all but one measure had good internal consistency (ordinal reliability coefficient ≥ .7). Confirmatory factor analysis using tetrachoric correlation coefficients was stable across samples and supported the construct validity of the first two composite measures. CONCLUSIONS: ADAPT is a reliable, validated instrument measuring the quality of HCT preparation experiences reported by adolescents with chronic disease. ADAPT will enable clinical programs and health care delivery systems to assess the quality of HCT preparation and provide targets for improvement in adolescent counseling related to transition.

Prevalence of Parental Misconceptions About Antibiotic Use.

BACKGROUND: Differences in antibiotic knowledge and attitudes between parents of Medicaid-insured and commercially insured children have been previously reported. It is unknown whether understanding has improved and whether previously identified differences persist. METHODS: A total of 1500 Massachusetts parents with a child <6 years old insured by a Medicaid managed care or commercial health plan were surveyed in spring 2013. We examined antibiotic-related knowledge and attitudes by using χ(2) tests. Multivariable modeling was used to assess current sociodemographic predictors of knowledge and evaluate changes in predictors from a similar survey in 2000. RESULTS: Medicaid-insured parents in 2013 (n = 345) were younger, were less likely to be white, and had less education than those commercially insured (n = 353), P < .01. Fewer Medicaid-insured parents answered questions correctly except for one related to bronchitis, for which there was no difference (15% Medicaid vs 16% commercial, P < .66). More parents understood that green nasal discharge did not require antibiotics in 2013 compared with 2000, but this increase was smaller among Medicaid-insured (32% vs 22% P = .02) than commercially insured (49% vs 23%, P < .01) parents. Medicaid-insured parents were more likely to request unnecessary antibiotics in 2013 (P < .01). Multivariable models for predictors of knowledge or attitudes demonstrated complex relationships between insurance status and sociodemographic variables. CONCLUSIONS: Misconceptions about antibiotic use persist and continue to be more prevalent among parents of Medicaid-insured children. Improvement in understanding has been more pronounced in more advantaged populations. Tailored efforts for socioeconomically disadvantaged populations remain warranted to decrease parental drivers of unnecessary antibiotic prescribing.

Predictors of timing of transfer from pediatric- to adult-focused primary care.

IMPORTANCE: A timely, well-coordinated transfer from pediatric- to adult-focused primary care is an important component of high-quality health care, especially for youths with chronic health conditions. Current recommendations suggest that primary-care transfers for youths occur between 18 and 21 years of age. However, the current epidemiology of transfer timing is unknown. OBJECTIVE: To examine the timing of transfer to adult-focused primary care providers (PCPs), the time between last pediatric-focused and first adult-focused PCP visits, and the predictors of transfer timing. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of patients insured by Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan. Our sample included 60 233 adolescents who were continuously enrolled in HPHC from 16 to at least 18 years of age between January 2000 and December 2012. Pediatric-focused PCPs were identified by the following provider specialty types, but no others: pediatrics, adolescent medicine, or pediatric nurse practitioner. Adult-focused PCPs were identified by having any provider type that sees adult patients. Providers with any specialty provider designation (eg, gastroenterology or gynecology) were not considered PCPs. MAIN OUTCOMES AND MEASURES: We used multivariable Cox proportional hazards regression to model age at first adult-focused PCP visit and time from the last pediatric-focused to the first adult-focused PCP visit (gap) for any type of office visit and for those that were preventive visits. RESULTS: Younger age at transfer was observed for female youths (hazard ratio [HR], 1.32 [95% CI, 1.29-1.36]) who had complex (HR, 1.06 [95% CI, 1.01-1.11]) or noncomplex (HR, 1.08 [95% CI, 1.05-1.12]) chronic conditions compared with those who had no chronic conditions. Transfer occurred at older ages for youths who lived in lower-income neighborhoods compared with those who lived in higher-income neighborhoods (HR, 0.89 [95% CI, 0.83-0.95]). The gap between last pediatric-focused to first adult-focused PCP visit was shorter for female youths than male youths (HR, 1.57 [95% CI, 1.53-1.61]) and youths with complex (HR, 1.35 [95% CI, 1.28-1.41]) or noncomplex (HR, 1.24 [95% CI, 1.20-1.28]) chronic conditions. The gap was longer for youths living in lower-income neighborhoods than for those living in higher-income neighborhoods (HR, 0.80 [95% CI, 0.75-0.85]). Multivariable models showed an adjusted median age at transfer of 21.8 years for office visits and 23.1 years for preventive visits and an adjusted median gap length of 20.5 months for office visits and 41.6 months for preventive visits. CONCLUSIONS AND RELEVANCE: Most youths are transferring care later than recommended and with gaps of more than a year. While youths with chronic conditions have shorter gaps, they may need even shorter transfer intervals to ensure continuous access to care. More work is needed to determine whether youths are experiencing clinically important lapses in care or other negative health effects due to the delayed timing of transfer.

Attributable healthcare utilization and cost of pneumonia due to drug-resistant streptococcus pneumonia: a cost analysis.

BACKGROUND: The burden of disease due to S. pneumoniae (pneumococcus), particularly pneumonia, remains high despite the widespread use of vaccines. Drug resistant strains complicate clinical treatment and may increase costs. We estimated the annual burden and incremental costs attributable to antibiotic resistance in pneumococcal pneumonia. METHODS: We derived estimates of healthcare utilization and cost (in 2012 dollars) attributable to penicillin, erythromycin and fluoroquinolone resistance by taking the estimate of disease burden from a previously described decision tree model of pneumococcal pneumonia in the U.S. We analyzed model outputs assuming only the existence of susceptible strains and calculating the resulting differences in cost and utilization. We modeled the cost of resistance from delayed resolution of illness and the resulting additional health services. RESULTS: Our model estimated that non-susceptibility to penicillin, erythromycin and fluoroquinolones directly caused 32,398 additional outpatient visits and 19,336 hospitalizations for pneumococcal pneumonia. The incremental cost of antibiotic resistance was estimated to account for 4% ($91 million) of direct medical costs and 5% ($233 million) of total costs including work and productivity loss. Most of the incremental medical cost ($82 million) was related to hospitalizations resulting from erythromycin non-susceptibility. Among patients under age 18 years, erythromycin non-susceptibility was estimated to cause 17% of hospitalizations for pneumonia and $38 million in costs, or 39% of pneumococcal pneumonia costs attributable to resistance. CONCLUSIONS: We estimate that antibiotic resistance in pneumococcal pneumonia leads to substantial healthcare utilization and cost, with more than one-third driven by macrolide resistance in children. With 5% of total pneumococcal costs directly attributable to resistance, strategies to reduce antibiotic resistance or improve antibiotic selection could lead to substantial savings.

Recent trends in outpatient antibiotic use in children.

OBJECTIVE: The goal of this study was to determine changes in antibiotic-dispensing rates among children in 3 health plans located in New England [A], the Mountain West [B], and the Midwest [C] regions of the United States. METHODS: Pharmacy and outpatient claims from September 2000 to August 2010 were used to calculate rates of antibiotic dispensing per person-year for children aged 3 months to 18 years. Differences in rates by year, diagnosis, and health plan were tested by using Poisson regression. The data were analyzed to determine whether there was a change in the rate of decline over time. RESULTS: Antibiotic use in the 3- to <24-month age group varied at baseline according to health plan (A: 2.27, B: 1.40, C: 2.23 antibiotics per person-year; P < .001). The downward trend in antibiotic dispensing slowed, stabilized, or reversed during this 10-year period. In the 3- to <24-month age group, we observed 5.0%, 9.3%, and 7.2% annual declines early in the decade in the 3 plans, respectively. These dropped to 2.4%, 2.1%, and 0.5% annual declines by the end of the decade. Third-generation cephalosporin use for otitis media increased 1.6-, 15-, and 5.5-fold in plans A, B, and C in young children. Similar attenuation of decline in antibiotic use and increases in use of broad-spectrum agents were seen in other age groups. CONCLUSIONS: Antibiotic dispensing for children may have reached a new plateau. Along with identifying best practices in low-prescribing areas, decreasing broad-spectrum use for particular conditions should be a continuing focus of intervention efforts.

Health care transition in young adults with type 1 diabetes: barriers to timely establishment of adult diabetes care.

OBJECTIVE: To examine barriers to health care transition reported by young adults with type 1 diabetes and associations between barriers and prolonged gaps between pediatric and adult diabetes care. METHODS: We surveyed young adults aged 22 to 30 years with type 1 diabetes about their transition experiences, including barriers to timely establishment of adult diabetes care. We evaluated relationships between barriers and gaps in care using multivariate logistic regression. RESULTS: The response rate was 53% (258 of 484 eligible subjects). Respondents (62% female) were 26.7 ± 2.4 years old and transitioned to adult diabetes care at 19.5 ± 2.9 years. Reported barriers included lack of specific adult provider referral name (47%) or contact information (27%), competing life priorities (43%), difficulty getting an appointment (41%), feeling upset about leaving pediatrics (24%), and insurance problems (10%). In multivariate analysis, barriers most strongly associated with gaps in care >6 months were lack of adult provider name (odds ratio [OR], 6.1; 95% confidence interval [CI], 3.0-12.7) or contact information (OR, 5.3; 95% CI, 2.0-13.9), competing life priorities (OR, 5.2; 95% CI, 2.7-10.3), and insurance problems (OR, 3.5; 95% CI, 1.2-10.3). Overall, respondents reporting ≥1 moderate/major barrier (48%) had 4.7-fold greater adjusted odds of a gap in care >6 months (95% CI, 2.8-8.7). CONCLUSION: Significant barriers to transition, such as a lack of specific adult provider referrals, may be addressed with more robust preparation by pediatric providers and care coordination. Further study is needed to evaluate strategies to improve young adult self-care in the setting of competing life priorities.

Evaluating the implementation of expert committee recommendations for obesity assessment.

The increasing prevalence of childhood overweight/obesity and their associated morbidities are well established, yet rates of diagnosis and screening for related conditions by clinicians are low. Expert Committee recommendations were released in 2007 to facilitate management of pediatric overweight/obesity. From well-child visits to a Massachusetts multisite group practice, we randomly selected 1 visit per child in 2006 (n = 56 374) and in 2008 (n = 69 681) and used electronic health record data to identify children with incident overweight or obesity (BMI ≥ 85th percentile) and ascertained whether clinicians assigned relevant ICD-9 (International Classification of Diseases, Ninth Revision) codes and ordered laboratory tests recommended for children ≥10 years old. In the year following the release of recommendations, a large majority of children 2 to 17 years old with a BMI ≥85th percentile lack diagnosis codes for overweight/obesity and recommended laboratory orders for assessment of obesity-related comorbidities for children 10 years and older, suggesting the need to augment current approaches to increase uptake of guidelines.

Aging population and future burden of pneumococcal pneumonia in the United States.

Pneumococcal pneumonia is concentrated among the elderly. Using a decision analytic model, we projected the future incidence of pneumococcal pneumonia and associated healthcare utilization and costs accounting for an aging US population. Between 2004 and 2040, as the population increases by 38%, pneumococcal pneumonia hospitalizations will increase by 96% (from 401 000 to 790 000), because population growth is fastest in older age groups experiencing the highest rates of pneumococcal disease. Absent intervention, the total cost of pneumococcal pneumonia will increase by $2.5 billion annually, and the demand for healthcare services for pneumococcal pneumonia, especially inpatient capacity, will double in coming decades.

Healthcare utilization and cost of pneumococcal disease in the United States.

BACKGROUND: Streptococcus pneumoniae continues to cause a variety of common clinical syndromes, despite vaccination programs for both adults and children. The total U.S. burden of pneumococcal disease is unknown. METHODS: We constructed a decision tree-based model to estimate U.S. healthcare utilization and costs of pneumococcal disease in 2004. Data were obtained from the 2004-2005 National (Hospital) Ambulatory Medical Care Surveys (outpatient visits, antibiotics) and the National Hospital Discharge Survey (hospitalization rates), and CDC surveillance data. Other assumptions regarding the incidence of each syndrome due to pneumococcus, expected health outcomes, and healthcare utilization were derived from literature and expert opinion. Healthcare and time costs used 2007 dollars. RESULTS: We estimate that, in 2004, pneumococcal disease caused 4.0 million illness episodes, 22,000 deaths, 445,000 hospitalizations, 774,000 emergency department visits, 5.0 million outpatient visits, and 4.1 million outpatient antibiotic prescriptions. Direct medical costs totaled $3.5 billion. Pneumonia (866,000 cases) accounted for 22% of all cases and 72% of pneumococcal costs. In contrast, acute otitis media and sinusitis (1.5 million cases each) comprised 75% of cases but only 16% of direct medical costs. Patients ≥ 65 years old, accounted for most serious cases and the majority of direct medical costs ($1.8 billion in healthcare costs annually). In this age group, pneumonia caused 242,000 hospitalizations, 1.4 million hospital days, 194,000 emergency department visits, 374,000 outpatient visits, and 16,000 deaths. However, if work loss and productivity are considered, the cost of pneumococcal disease among younger working adults (18-<50) nearly equaled those ≥ 65. CONCLUSIONS: Pneumococcal disease remains a substantial cause of morbidity and mortality even in the era of routine pediatric and adult vaccination. Continued efforts are warranted to reduce serious pneumococcal disease, especially adult pneumonia.

Utilization of healthcare resources by U.S. children and adults with inflammatory bowel disease.

BACKGROUND: The inflammatory bowel diseases (IBDs) Crohn's disease (CD) and ulcerative colitis (UC) affect over 1 million people in the United States, yet little is known about healthcare utilization by affected individuals. The objectives were to describe the healthcare utilization associated with IBD in an insured U.S. population and to determine how sociodemographic factors impact healthcare utilization in this population. METHODS: Using an administrative database comprised of 87 health plans, we ascertained cases of CD and UC using an administrative definition. We identified inpatient, office-based, emergency (ED), and endoscopy services occurring between 2003-2004 in IBD patients and matched controls. For each case, excess utilization was determined by subtracting the mean number of control visits from the number of case visits. Multivariate logistic and linear regressions were used to identify the sociodemographic factors associated with excess utilization. RESULTS: We identified 9056 CD patients and 10,364 UC patients. The mean number of annual excess hospitalizations, ED visits, and office visits per 100 patients for CD were 21.7, 20.1, and 493, respectively. These values for UC were 13.3, 10.3, and 364, respectively. In general, utilization was higher in CD compared with UC, and in younger patients compared with older patients. Utilization also varied by gender, geographical region, and insurance type (Medicaid versus commercial). CONCLUSIONS: In the U.S., patients with IBD consume substantial healthcare resources. Resource utilization varies by patient age and disease type, and to a lesser extent, gender, geographical region, and insurance type. These findings may be used to inform health policy.