Disease Burden and Inpatient Management of Children with Acute Respiratory Viral Infections during the Pre-COVID Era in Germany: A Cost-of-Illness Study.

Respiratory viral infections (RVIs) are common reasons for healthcare consultations. The inpatient management of RVIs consumes significant resources. From 2009 to 2014, we assessed the costs of RVI management in 4776 hospitalized children aged 0-18 years participating in a quality improvement program, where all ILI patients underwent virologic testing at the National Reference Centre followed by detailed recording of their clinical course. The direct (medical or non-medical) and indirect costs of inpatient management outside the ICU ('non-ICU') versus management requiring ICU care ('ICU') added up to EUR 2767.14 (non-ICU) vs. EUR 29,941.71 (ICU) for influenza, EUR 2713.14 (non-ICU) vs. EUR 16,951.06 (ICU) for RSV infections, and EUR 2767.33 (non-ICU) vs. EUR 14,394.02 (ICU) for human rhinovirus (hRV) infections, respectively. Non-ICU inpatient costs were similar for all eight RVIs studied: influenza, RSV, hRV, adenovirus (hAdV), metapneumovirus (hMPV), parainfluenza virus (hPIV), bocavirus (hBoV), and seasonal coronavirus (hCoV) infections. ICU costs for influenza, however, exceeded all other RVIs. At the time of the study, influenza was the only RVI with antiviral treatment options available for children, but only 9.8% of influenza patients (non-ICU) and 1.5% of ICU patients with influenza received antivirals; only 2.9% were vaccinated. Future studies should investigate the economic impact of treatment and prevention of influenza, COVID-19, and RSV post vaccine introduction.

Design and validation of indicators for the comprehensive measurement of quality of care for type 2 diabetes and acute respiratory infections in ambulatory health services.

Developing ambulatory health services (AHS) of optimal quality is a pending issue for many health systems at a global level, especially in middle- and low-income countries. An effective health response requires indicators to measure the quality of care that are context-specific and feasible for routine monitoring. This paper aimed to design and validate indicators for assessing the technical and interpersonal quality dimensions for type 2 diabetes (T2D) and acute respiratory infections (ARI) care in AHS. The study was conducted in two stages. First, technical and user-centered-based indicators of quality of care for T2D and ARI care were designed following international recommendations, mainly from the American Diabetes Association standards and the National Institute for Health and Care Excellence guidelines. We then assessed the validity, reliability, relevance, and feasibility of the proposed indicators implementing the modified Delphi technique. A panel of 17 medical experts from five countries scored the indicators using two electronic questionnaires, one for each reason for consultation selected, sent by email in two sequential rounds of rating. We defined the levels of consensus according to the overall median for each performance category, which was established as the threshold. Selected indicators included those with scores equal to or higher than the threshold. We designed 36 T2D indicators, of which 16 were validated for measuring the detection of risks and complications, glycemic control, pharmacological treatment, and patient-centered care. Out of the 22 indicators designed for ARI, we validated 10 for diagnosis, appropriate prescription of antimicrobials, and patient-centered care. The validated indicators showed consistency for the dimensions analyzed. Hence, they proved to be a potentially reliable and valuable tool for monitoring the performance of the various T2D and ARI care processes in AHS. Further research will be needed to verify the applicability of the validated indicators in routine clinical practice.

Impact of Nonpharmacological Interventions on Severe Acute Respiratory Infections in Children: From the National Surveillance Database.

BACKGROUND: Nonpharmacological interventions (NPIs) reduce the incidence of respiratory infections. After NPIs imposed during the coronavirus disease 2019 pandemic ceased, respiratory infections gradually increased worldwide. However, few studies have been conducted on severe respiratory infections requiring hospitalization in pediatric patients. This study compares epidemiological changes in severe respiratory infections during pre-NPI, NPI, and post-NPI periods in order to evaluate the effect of that NPI on severe respiratory infections in children. METHODS: We retrospectively studied data collected at 13 Korean sentinel sites from January 2018 to October 2022 that were lodged in the national Severe Acute Respiratory Infections (SARIs) surveillance database. RESULTS: A total of 9,631 pediatric patients were admitted with SARIs during the pre-NPI period, 579 during the NPI period, and 1,580 during the post-NPI period. During the NPI period, the number of pediatric patients hospitalized with severe respiratory infections decreased dramatically, thus from 72.1 per 1,000 to 6.6 per 1,000. However, after NPIs ceased, the number increased to 22.8 per 1,000. During the post-NPI period, the positive test rate increased to the level noted before the pandemic. CONCLUSION: Strict NPIs including school and daycare center closures effectively reduced severe respiratory infections requiring hospitalization of children. However, childcare was severely compromised. To prepare for future respiratory infections, there is a need to develop a social consensus on NPIs that are appropriate for children.

Costs of management of acute respiratory infections in older adults: A systematic review and meta-analysis.

Background: Acute respiratory infections (ARIs) accounted for an estimated 3.9 million deaths worldwide in 2015, of which 56% occurred in adults aged 60 years or older. We aimed to identify the cost of ARI management in older adults (≥50 years) in order to develop an evidence base to assist decision-making for resource allocation and inform clinical practice. Methods: We searched 8 electronic databases including Global Health, Medline and EMBASE for studies published between January 1, 2000 and December 31, 2021. Total management costs per patient per ARI episode were extracted and meta-analysis was conducted by World Health Organization (WHO) region and World Bank income level. All costs were converted and inflated to Euros (€) (2021 average exchange rate). The quality of included studies and the potential risk of bias were evaluated. Results: A total of 42 publications were identified for inclusion, reporting cost data for 8 082 752 ARI episodes in older adults across 20 countries from 2001 to 2021. The majority (86%) of studies involved high-income countries based in Europe, North America and Western Pacific. The mean cost per episode was €17 803.9 for inpatient management and €128.9 for outpatient management. Compared with costs reported for patients aged <65 years, inpatient costs were €154.1, €7 018.8 and €8 295.6 higher for patients aged 65-74 years, 75-84 years and over 85 years. ARI management of at-risk patients with comorbid conditions and patients requiring higher level of care, incurred substantially higher costs for hospitalization: €735.9 and €1317.3 respectively. Conclusions: ARIs impose a substantial economic burden on health systems, governments, patients and societies. This study identified high ARI management costs in older adults, reinforcing calls for investment by global health players to quantify and address the scale of the challenge. There are large gaps in data availability from low-income countries, especially from South East Asia and Africa regions.

Evaluating a community respiratory physiotherapy service for children with neurodisability.

BACKGROUND: Children with neurodisability are at an increased risk of respiratory problems and complications, which often result in prolonged, frequent hospital admissions and are the biggest cause of mortality in this client group. The Children's Community Respiratory Physiotherapy Service (CCRPS) was established in 2010 to support children with severe neurodisabilities at home during acute chest infections and to prevent emergency department attendances and hospital admissions. This service evaluation looked at patient/parent satisfaction and prevented admissions to ensure clinical and cost-effectiveness, despite the rising demand for the service. METHODS: Over a 3-month period, patients and parents/carers on the CCRPS caseload were given a Picker feedback survey following 100 emergency visits from the team. The number of prevented hospital admissions for respiratory tract infection over 12 months (April 2019-March 2020) was identified from existing CCRPS data and hospital admissions costs saved were estimated. RESULTS: The Picker survey responses were extremely positive with all respondents reporting that they felt well looked after and that the main reason for the emergency visit was dealt with well. Based on key indicators, the CCRPS prevented 182 hospital admissions for respiratory tract infection in 2019/2020, equating to 1638 bed days and estimated cost savings ranging between £751 728 and £1 009 986. CONCLUSIONS: The Picker survey response demonstrates the positive impact that the CCRPS has on both quality of life and experience for patients and families. The CCRPS rapid response service prevents hospital admissions for respiratory tract infections in children and young people with severe neurodisability and the cost savings from admissions prevented allows the service to more than pay for itself.

Quality of care for children with acute respiratory infections in health facilities: a comparative analysis of assessment tools.

Background: Severe childhood pneumonia requires treatment in hospital by trained health care workers. It is therefore important to determine if health facilities provide quality health services for children with acute respiratory infections (ARI), including pneumonia. Using established indicators from WHO to measure quality of care (QoC) as a reference standard, this review aims to evaluate how well existing tools assess QoC for children presenting to health facilities with ARI. Methods: Existing assessment tools identified from a published systematic literature review that evaluated QoC assessment tools for children (<15 years) in health facilities for all health conditions were included in this ARI-specific review. 27 ARI-specific indicators or "quality measures" from the WHO "Standards for improving quality of care for children and young adolescents in health facilities" were selected for use as a reference standard to assess QoC for children presenting to health facilities with ARI symptoms. Each included assessment tool was evaluated independently by two paediatricians to determine how many of the WHO ARI quality measures were assessable by the tool. The assessment tools were then ranked in order of percentage of ARI quality measures assessable. Results: Nine assessment tools that assessed QoC for children attending health facilities were included. Two hospital care tools developed by WHO had the most consistency with ARI-specific indicators, assessing 22/27 (81.5%) and 20/27 (74.1%) of the quality measures. The remaining tools were less consistent with the ARI-specific indicators, including between zero to 16 of the 27 quality measures. The most common indicators absent from the tools were assessment of appropriate use of pulse oximetry and administration of oxygen, how often oxygen supply was unavailable, and mortality rates. Conclusions: The existing WHO hospital-based QoC assessment tools are comprehensive but could be enhanced by improved data quality around oxygen availability and appropriate use of pulse oximetry and oxygen administration. Any tools, however, should be considered within broader assessments of QoC, rather than utilised in isolation. Further adaptation to local settings will improve feasibility and facilitate progress in the delivery of quality health care for children with ARI. Registration: The protocol of the original systematic review was registered in PROSPERO ID: CRD42020175652.

Temporal Trends, Management and Outcomes of Acute Myocardial Infarction with Concomitant Respiratory Infections.

There are limited contemporary data on the management and outcomes of acute myocardial infarction (AMI) in patients with concomitant acute respiratory infections. Hence, using the National Inpatient Sample from 2000-2017, adult AMI admissions with and without concomitant respiratory infections were identified. We evaluated in-hospital mortality, utilization of cardiac procedures, hospital length of stay, hospitalization costs, and discharge disposition. Among 10,880,856 AMI admissions, respiratory infections were identified in 745,536 (6.9%). Temporal trends revealed a relatively stable tr end with a peak during 2008-2009. Admissions with respiratory infections were on average older (74 vs. 67 years), female (45% vs 39%), with greater comorbidity (mean Charlson comorbidity index 5.9 ± 2.2 vs 4.4 ± 2.3), and had higher rates of non-ST-segment-elevation AMI presentation (71.8% vs. 62.2%) (all p < 0.001). Higher rates of cardiac arrest (8.2% vs 4.8%), cardiogenic shock (10.7% vs 4.4%), and acute organ failure (27.8% vs 8.1%) were seen in AMI admissions with respiratory infections. Coronary angiography (41.4% vs 65.6%, p < 0.001) and percutaneous coronary intervention (20.7% vs 43.5%, p < 0.001) were used less commonly in those with respiratory infections. Admissions with respiratory infections had higher in-hospital mortality (14.5% vs 5.5%; propensity matched analysis: 14.6% vs 12.5%; adjusted odds ratio 1.25 [95% confidence interval 1.24-1.26], p < 0.001), longer hospital stay, higher hospitalization costs, and less frequent discharges to home compared to those without respiratory infections. In conclusion, respiratory infections significantly impact AMI admissions with higher rates of complications, mortality and resource utilization.

Estimated incidence of juvenile-onset recurrent respiratory papillomatosis in Korea.

OBJECTIVES: Recurrent respiratory papillomatosis (RRP) is caused by human papillomavirus (HPV) types 6 and 11 and is potentially preventable through vaccination. This study estimated the incidence of juvenile-onset RRP before the implementation of the national HPV vaccination program in Korea. METHODS: We conducted a cohort study using claims data provided by a mandatory insurance program to estimate the incidence of RRP and associated healthcare use. Patients with juvenile RRP were defined as those aged ≤12 years with ≥2 admissions or ≥2 outpatient visits during which they received the International Classification of Diseases, 10th revision code for benign neoplasms of the larynx (D14.1). RESULTS: During 2002-2014, 123 children (74 boys and 49 girls) were diagnosed with RRP. The patients had a mean of 6.5 person-years of follow-up. The incidence was estimated at 0.30/100,000 person-years. The median age at diagnosis was 4.0 years (mean, 4.3). Thirty-six (29.3%) patients underwent surgery, including 23 patients (18.7%) who underwent 2 or more surgical procedures. Severe disease, measured by more frequent surgical procedures and shorter time intervals between consecutive operations, was associated with a younger age at diagnosis. CONCLUSIONS: The estimated incidence of juvenile-onset RRP in Korea was similar to that reported in other countries. The RRP burden should continue to be monitored using National Health Insurance Service claims data.

Where Do Caregivers Take Their Sick Children for Care? An Analysis of Care Seeking and Equity in 24 USAID Priority Countries.

Pneumonia, diarrhea, and malaria are leading causes of under-5 mortality. Accelerated reductions in illness burden are needed to meet childhood Sustainable Development Goals. Understand-ing where parents take sick children for care is key to improving equitable, high-quality treatment for these childhood illnesses and catalyzing reductions in morbidity and mortality. We analyzed the most recent Demographic and Health Survey data in 24 of the United States Agency for International Development's maternal and child health priority countries to examine levels and sources of care for children sick with 3 illness classifications: symptoms of acute respiratory infection, diarrhea, or fever. On average, across countries analyzed, one-third of children had recent experience with at least 1 of the 3 classifications. The majority (68.2%) of caregivers sought external advice or treatment for their sick children, though the level is far higher for the wealthiest (74.3%) than poorest (63.1%) families. Among those who sought out-of-home care, 51.1% used public sources and 42.5% used private-sector sources. Although sources for sick child care varied substantially by region and country, they were consistent across the 3 illness classifications. Urban and wealthier families reported more use of private sources compared with rural and poorer families. Though 35.2% of the poorest families used private sources, most of these (57.2%) were retail outlets like pharmacies and shops, while most wealthier families who sought care in the private sector went to health facilities (62.4%). Efforts to strengthen the quality of integrated management of sick child care must therefore reach both public and private facilities as well as private pharmacies, shops, and other retail outlets. Stakeholders across sectors must collaborate to reach all population groups with high-quality child health services and reduce disparities in care-seeking behaviors. Such cross-sectoral efforts will build clinical and institutional capacity and more efficiently allocate resources, ultimately resulting in stronger, more resilient health systems.

Respiratory tract infections (RTIs) in primary care: narrative review of C reactive protein (CRP) point-of-care testing (POCT) and antibacterial use in patients who present with symptoms of RTI.

Antimicrobial resistance (AMR) continues to be a global problem and continues to be addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. Patients who attend general (ambulatory) practice with symptoms of respiratory tract infections (RTIs) are invariably assessed by some sort of clinical decision rule (CDR). However, CDRs rely on a cluster of non-specific clinical observations. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) point-of-care testing (POCT) to guide antibacterial prescribing in adult patients presenting to general practitioner (GP) practices with symptoms of RTI. Studies that were included were Cochrane reviews, systematic reviews, randomised controlled trials, cluster randomised trials, controlled before and after studies, cohort studies and economic evaluations. An overwhelming number of studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces index antibacterial prescribing. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. With the rapid development of artificial intelligence, patients will expect greater precision in diagnosing and managing their illnesses. Adopting systems that markedly reduce antibiotic consumption is a no-brainer for governments that are struggling to address the rise in AMR.

Intensive care inequity in Rio de Janeiro: the effect of spatial distribution of health services on severe acute respiratory infection. / Desigualdades na terapia intensiva no Rio de Janeiro: efeitos da distribuição espacial dos serviços de saúde na infecção respiratória aguda grave.

OBJECTIVE: To analyze the distribution of adult intensive care units according to geographic region and health sector in Rio de Janeiro and to investigate severe acute respiratory infection mortality in the public sector and its association with critical care capacity in the public sector. METHODS: We evaluated the variation in intensive care availability and severe acute respiratory infection mortality in the public sector across different areas of the city in 2014. We utilized databases from the National Registry of Health Establishments, the Brazilian Institute of Geography and Statistics, the National Mortality Information System and the Hospital Admission Information System. RESULTS: There is a wide range of intensive care unit beds per capita (from 4.0 intensive care unit beds per 100,000 people in public hospitals in the West Zone to 133.6 intensive care unit beds per 100,000 people in private hospitals in the Center Zone) in the city of Rio de Janeiro. The private sector accounts for almost 75% of the intensive care unit bed supply. The more developed areas of the city concentrate most of the intensive care unit services. Map-based spatial analysis shows a lack of intensive care unit beds in vast territorial extensions in the less developed regions of the city. There is an inverse correlation (r = -0.829; 95%CI -0.946 to -0.675) between public intensive care unit beds per capita in different health planning areas of the city and severe acute respiratory infection mortality in public hospitals. CONCLUSION: Our results show a disproportionate intensive care unit bed provision across the city of Rio de Janeiro and the need for a rational distribution of intensive care.

Agammaglobulinemia: Epidemiology, Pathogenesis, Clinical Phenotype, Diagnosis, Prognosis and Management.

Agammaglobulinemia is a type of primary antibody deficiencies, characterized by severe reduction in serum level of all types of immunoglobulins level and absence of B cells in the peripheral blood. X-linked and various autosomal recessive/dominant mutations have been identified underlying the pathogenesis of this disorder. Affected patients present a broad range of clinical manifestations, including respiratory infections, gastrointestinal complications, Enterovirus infections, autoimmunity, and malignancies. This disease can be controlled by different therapeutic strategies. In this review, we describe different aspects of agammaglobulinemia such as epidemiology, pathogenesis, clinical phenotype, diagnosis, management, and prognosis of congenital agammaglobulinemia.

Determinants of acute respiratory infection (ARI) among under-five children in rural areas of Legambo District, South Wollo Zone, Ethiopia: A matched case-control study.

BACKGROUND: Acute respiratory infection (ARI) leads to morbidity and mortality among under-fivechildren in developing countries, especially in rural settings. ARI ranks among the top 10 diseases in under-five children in Legambo District, South Wollo Zone, Ethiopia. The aim of this study was to evaluate determinant factors for ARI in Legambo District in 2019. MATERIALS AND METHODS: A community-based matched case-control study was conducted, involving 139 cases and 278 controls under 5 years of age, from mid-January to mid-February 2019. Data were collected using a structured questionnaire. Bivariate and multivariable conditional logistic regression analyses were performed. From the multivariable conditional logistic regression analysis, variables with a significance level of p < 0.05 were taken as significantly associated with ARI among under-five children. RESULT: ARI among children under 5 years of age was significantly associated with age of the mother/caregiver being ≥35 years, occupation of mother/caregiver being housewife, the family being of medium wealth status, the type of stove used in the house, carrying the child while preparing food, absence of windows in the house, and nutritional status of the child. CONCLUSION: The occurrence of ARI could be reduced by improving economic status, stove use, and nutrition of children, and by increasing community awareness regarding indoor air pollution and ventilation.

[Impact of Chest Physical Therapy on Length of Stay and Medical Expenditures for Patients With Pulmonary Infection].

BACKGROUND: Sputum retention increases significantly the risk of repetitive respiratory tract infections, which may result in dyspnea and lung injury. Chest physical therapy is the most commonly used method to assist patients to expel sputum. This intervention promotes sputum clearance and prevents airway obstruction, thereby reducing the risk of lung infection. PURPOSE: The purpose of this study was to investigate the impact of chest physical therapy on the length of hospitalization and the medical expenditures of patients with pulmonary infection. METHODS: A retrospective-correlation study was used. Data were collected from 2013 to 2017 in the medical ward of a medical center located in southern Taiwan. The annual differences in the length of stay, medical expenditures, and readmission rates for patients with pulmonary infection after chest physical therapy were analyzed. RESULTS: A total of 707 patients with pulmonary infection were recruited and enrolled as participants. The mean age of the participants was 75.4 (± 13.8) years. The results showed that length of stay (F = 6.66, p < .001) and medical expenditures (F = 5.34, p < .001) were both significantly lower after chest physical therapy and that the corresponding readmission rates had decreased significantly, from 6.9% in 2013 to 1.7% in 2017 (x2 = 5.84, p = .016). CONCLUSIONS / IMPLICATIONS FOR PRACTICE: After conducting a yearly comparison, the results of this study indicate that administering chest physical therapy may be an effective strategy for reducing the length of stay, readmission rates, and medical expenditures of patients with pulmonary infection. The findings of this study may serve as a reference for the clinical implementation of chest physical therapy in patients with pulmonary infection.

Social Disadvantage, Access to Care, and Disparities in Physical Functioning Among Children Hospitalized with Respiratory Illness.

BACKGROUND AND OBJECTIVES: Understanding disparities in child health-related quality of life (HRQoL) may reveal opportunities for targeted improvement. This study examined associations between social disadvantage, access to care, and child physical functioning before and after hospitalization for acute respiratory illness. METHODS: From July 1, 2014, to June 30, 2016, children ages 8-16 years and/or caregivers of children 2 weeks to 16 years admitted to five tertiary care children's hospitals for three common respiratory illnesses completed a survey on admission and within 2 to 8 weeks after discharge. Survey items assessed social disadvantage (minority race/ ethnicity, limited English proficiency, low education, and low income), difficulty/delays accessing care, and baseline and follow-up HRQoL physical functioning using the Pediatric Quality of Life Inventory (PedsQL, range 0-100). We examined associations between these three variables at baseline and follow-up using multivariable, mixed-effects linear regression models with multiple imputation sensitivity analyses for missing data. RESULTS: A total of 1,325 patients and/or their caregivers completed both PedsQL assessments. Adjusted mean baseline PedsQL scores were significantly lower for patients with social disadvantage markers, compared with those of patients with none (78.7 for >3 markers versus 85.5 for no markers, difference -6.1 points (95% CI: -8.7, -3.5). The number of social disadvantage markers was not associated with mean follow-up PedsQL scores. Difficulty/delays accessing care were associated with lower PedsQL scores at both time points, but it was not a significant effect modifier between social disadvantage and PedsQL scores. CONCLUSIONS: Having social disadvantage markers or difficulty/delays accessing care was associated with lower baseline physical functioning; however, differences were reduced after hospital discharge.

Desigualdades na terapia intensiva no Rio de Janeiro: efeitos da distribuição espacial dos serviços de saúde na infecção respiratória aguda grave / Intensive care inequity in Rio de Janeiro: the effect of spatial distribution of health services on severe acute respiratory infection

RESUMO Objetivo: Analisar a distribuição das unidades de terapia intensiva para adultos, segundo a região geográfica e o setor sanitário no Rio de Janeiro, e investigar a mortalidade por infecção respiratória aguda grave no setor público e sua associação com a capacidade de terapia intensiva no setor público. Métodos: Avaliamos a variação da disponibilidade de terapia intensiva e a mortalidade por infecção respiratória aguda grave no setor público em diferentes áreas da cidade em 2014. Utilizamos as bases de dados do Cadastro Nacional de Estabelecimentos de Saúde, do Instituto Brasileiro de Geografia e Estatística, do Sistema de Informações sobre Mortalidade e do Sistema de Informações Hospitalares do SUS. Resultados: Foi ampla a variação na disponibilidade de leitos em unidades de terapia intensiva per capita (desde 4,0 leitos de terapia intensiva por 100 mil habitantes em hospitais públicos na zona oeste até 133,6 leitos em unidades de terapia intensiva por 100 mil habitantes nos hospitais privados na zona central) na cidade do Rio de Janeiro. O setor privado respondeu pelo suprimento de quase 75% dos leitos em unidades de terapia intensiva. Uma análise espacial com base em mapas mostrou falta de leitos em unidades de terapia intensiva em vastas extensões territoriais nas regiões menos desenvolvidas da cidade. Houve correlação inversa (r = -0,829; IC95% -0,946 - -0,675) entre a quantidade de leitos públicos em unidade de terapia intensiva per capita em diferentes áreas de planejamento em saúde na cidade e a mortalidade por infecção respiratória aguda grave em hospitais públicos. Conclusão: Nossos resultados mostram disponibilidade desproporcional de leitos em unidades de terapia intensiva na cidade do Rio de Janeiro e a necessidade de uma distribuição racional da terapia intensiva.

ABSTRACT Objective: To analyze the distribution of adult intensive care units according to geographic region and health sector in Rio de Janeiro and to investigate severe acute respiratory infection mortality in the public sector and its association with critical care capacity in the public sector. Methods: We evaluated the variation in intensive care availability and severe acute respiratory infection mortality in the public sector across different areas of the city in 2014. We utilized databases from the National Registry of Health Establishments, the Brazilian Institute of Geography and Statistics, the National Mortality Information System and the Hospital Admission Information System. Results: There is a wide range of intensive care unit beds per capita (from 4.0 intensive care unit beds per 100,000 people in public hospitals in the West Zone to 133.6 intensive care unit beds per 100,000 people in private hospitals in the Center Zone) in the city of Rio de Janeiro. The private sector accounts for almost 75% of the intensive care unit bed supply. The more developed areas of the city concentrate most of the intensive care unit services. Map-based spatial analysis shows a lack of intensive care unit beds in vast territorial extensions in the less developed regions of the city. There is an inverse correlation (r = -0.829; 95%CI -0.946 to -0.675) between public intensive care unit beds per capita in different health planning areas of the city and severe acute respiratory infection mortality in public hospitals. Conclusion: Our results show a disproportionate intensive care unit bed provision across the city of Rio de Janeiro and the need for a rational distribution of intensive care.

Impact of the Choosing Wisely® Campaign Recommendations for Hospitalized Children on Clinical Practice: Trends from 2008 to 2017.

BACKGROUND: The Choosing Wisely® Campaign (CWC) was launched in 2012. Five recommendations to reduce the use of "low-value" services in hospitalized children were published in 2013. OBJECTIVES: The aim of this study was to estimate the frequency and trends of utilization of these services in tertiary children's hospitals five years before and after the publication of the recommendations. METHODS: We conducted a retrospective, longitudinal analysis of hospitalizations to 36 children's hospitals from 2008 to 2017. The "low-value" services included (1) chest radiograph (CXR) for asthma, (2) CXR for bronchiolitis, (3) relievers for bronchiolitis, (4) systemic steroids for lower respiratory tract infection (LRTI), and (5) acid suppressor therapy for uncomplicated gastroesophageal reflux (GER). We estimated the annual percentages of the use of these services after risk adjustment, followed by an interrupted time series (ITS) analysis to compare trends before and after the publication of the recommendations. RESULTS: The absolute decreases in utilization were 36.6% in relievers and 31.5% in CXR for bronchiolitis, 24.1% in acid suppressors for GER, 20.8% in CXR for asthma, and 2.9% in steroids for LRTI. Trend analysis showed that one "low-value" service declined significantly immediately (use of CXR for asthma), and another decreased significantly over time (relievers for bronchiolitis) after the CWC. CONCLUSIONS: There was some decrease in the utilization of "low-value" services from 2008 to 2017. Limited changes in trends occurred after the publication of the recommendations. These findings suggest a limited impact of the CWC on clinical practice in these areas. Additional interventions are required for a more effective dissemination of the CWC recommendations for hospitalized children.