Rehospitalisation after birth hospitalisation: patterns among infants of all gestations.

AIM: To analyse rehospitalisation of newborns of all gestations. METHODS: A total of 33,276 surviving infants of all gestations born between 1 October 1998 and 31 March 2000 at seven Kaiser Permanente Medical Care Program (KPMCP) delivery services were studied retrospectively. RESULTS: Rehospitalisation rates within two weeks after nursery discharge ranged from 1.0% to 3.7%. The most common reason for rehospitalisation was jaundice. Among babies > or =34 weeks, the most important factor with respect to rehospitalisation was use of home phototherapy. Among babies who were not rehospitalised for jaundice, African-American race (adjusted odds ratio (AOR) = 0.56), and having a scheduled outpatient visit (AOR = 0.73) or a home visit (AOR = 0.59) within 72 hours after discharge were protective. Factors associated with increased risk were: being small for gestational age (AOR = 1.83), gestational age of 34-36 weeks without admission to the neonatal intensive care unit (AOR = 1.65), Score for Neonatal Acute Physiology, version II, > or =10 (AOR = 1.95), male gender (AOR = 1.24), having both a home as well as a clinic visit within 72 hours after discharge (AOR = 1.84), and birth facility (range of AORs = 1.52-2.36). Asian race was associated with rehospitalisation (AOR = 1.49) when all hospitalisations were considered, but this association did not persist if hospitalisations for jaundice were excluded. CONCLUSIONS: In this insured population with access to integrated care, rehospitalisation rates for jaundice were strongly affected by availability of home phototherapy and by follow up. For other causes, moderate prematurity and follow up visits played a large role, but variation between centres persisted even after controlling for multiple factors. Future research should include development of better process measures for evaluation of follow up strategies.

Population-based study of rotavirus vaccination and intussusception.

BACKGROUND: During the first year that the rhesus rotavirus tetravalent vaccine (RRV-TV) was licensed, the Vaccine Adverse Event Reporting System received several reports of intussusception after vaccination. To evaluate the risk of intussusception, we conducted a retrospective cohort study in ten managed care organizations. METHODS: Cases of intussusception were identified by searching electronic databases for diagnoses of intussusception (ICD-9 Code 560.0) in infants 1 to 11 months of age and confirmed by medical chart review. Vaccination and enrollment data were obtained from administrative databases. Incidence rate ratios (RR) of intussusception were computed by dividing incidence rates in prespecified risk intervals after vaccination by the background rate of intussusception and adjusted for age by Poisson regression. Cox proportional hazard regression was used to evaluate risk by vaccine dose. RESULTS: Of 463,277 children 56,253 had been vaccinated with a total of 91 371 doses of RRV-TV. The incidence rate of intussusception was 25/100,000 person years among unexposed infants and 340/100,000 person years 3 to 7 days postvaccination. In the interval 3 to 7 days after vaccination, the age-adjusted RR was 16.0 (95% confidence interval, 5.5 to 46.7) for all doses combined and 30.4 (95% confidence interval, 8.8 to 104.9) after the first dose. RRs for the 8- to 14- and 15- to 21-day risk intervals were >1.0, but the confidence intervals substantially overlapped 1.0. The attributable risk was one case of intussusception per 11 073 children vaccinated. CONCLUSIONS: RRV-TV is associated with an increased risk of intussusception. The risk is greatest 3 to 7 days after the first vaccination dose.

Smoking cessation interventions among hospitalized patients: what have we learned?

BACKGROUND: We conducted a structured review of controlled studies on inpatient hospital-based smoking cessation interventions. METHODS: Electronic searches were conducted with two different search engines, and reference sections of articles located were also reviewed. The RE-AIM framework was used to organize the review around the issues of reach, efficacy, adoption, implementation, and maintenance of interventions. RESULTS: Thirty-one intervention articles were located, 20 of which included a comparison condition and were included in the review. Overall, a moderate number of studies (13/20) reported on reach, which was highly variable and limited (30-50% in most studies), while few reported on implementation (7/20). Longer term cessation results produced relative risk ratios of 0.9-2.3, with a median of 1.5. Increases in quit rates above the control condition ranged from -1 to 10% (median 4%) among general admission patients and from 7 to 36% (median 15%) among cardiac admission patients. Studies with a dedicated smoking cessation counselor and 3-5 months of relapse prevention had a significant impact on cessation rates. Study settings (adoption) were limited to university, Veterans affairs, and HMO hospitals. Maintenance at the individual level was variable and related to the presence of a relatively intensive initial intervention and a sustained relapse prevention intervention. CONCLUSIONS: Efficacious inpatient smoking programs have been developed and validated. The challenge now is to translate these interventions more widely into practice, given changing hospitalization patterns.

Effect of a pediatric self-care book on utilization of services in a group model HMO.

The purpose of this study was to determine the effect of a pediatric self-care book (SCB) with nurse telephone support on use of health services. The study was performed in a pediatric department of Kaiser Permanente in a suburb of Denver, Colorado. Well patients seen at age 2 weeks to 2.5 months (infant group) or 14 to 19 months (toddler group) were enrolled. Intervention families received a copy of the book, Your Child's Health and were oriented on its use. Rates of sick visits, advice nurse calls, pharmacy prescriptions, emergency department visits, and hospital admissions were assessed. Visit and call rates were calculated, and mean rates of the SCB group and the control group were then compared. Of 1,104 enrols, 527 received the SCB; the other 577 served as controls. The SCB group had 14.0% fewer total visits (excluding well-baby visits) than controls did (p = 0.018). For infants and toddlers who were not first-borns, the intervention was associated with a statistically significant decrease in sick visits (23%), advice nurse phone calls (24%), and pharmacy prescriptions (26%); no statistically significant differences in study outcomes were seen among first-born study subjects. Promotion of self-care in a group model health maintenance organization can decrease use of services by families of young children.

The accuracy of a lead questionnaire in predicting elevated pediatric blood lead levels.

OBJECTIVES: To determine the prevalence of elevated blood lead levels and to evaluate the accuracy of a lead screening questionnaire in a western United States urban inner-city pediatric population. DESIGN: A convenience sample of children between the ages of 6 months and 6 years seen for a well-child visit were enrolled. Venous blood lead levels were measured and a lead screening questionnaire was completed. SETTING: The primary care clinics of the 10 community health centers of the city and county of Denver, Colorado. Approximately 85% of children receiving services are below the 150% poverty level and 54% are insured through the state's Medicaid program. SUBJECTS: A total of 2978 children seen for a well-child visit from February 1993 to January 1994. MAIN OUTCOME MEASURES: The prevalence of elevated blood lead levels and the operating characteristics of both the Centers for Disease Control and Prevention lead screening questionnaire and the complete questionnaire used in Denver, using venous blood lead levels as the criterion standard. RESULTS: The mean blood lead level was 0.20 mumol/L (4.19 micrograms/dL). Eighty-five children had blood lead levels of 0.48 mumol/L (10 micrograms/dL), representing 2.9% of the study group (95% confidence interval [CI], 2.3-3.5). Only 0.3% of the cohort had blood lead levels greater than 0.96 mumol/L (20 micrograms/dL). The sensitivity, specificity, and positive predictive value of the Centers for Disease Control and Prevention questionnaire was 57%, 51%, and 3%, respectively. The sensitivity, specificity, and positive predictive value of the complete questionnaire was 59.7%, 36%, and 2.6%, respectively. The marginal cost of identifying a child with a blood lead level greater than 0.96 mumol/L (20 micrograms/dL) was $4925. CONCLUSIONS: Few of the low-income children in this study had blood lead levels greater than 0.48 mumol/L (10 micrograms/dL). The questionnaire did little better than chance at predicting the presence or absence of elevated blood lead levels and cannot replace a blood lead level test for childhood lead screening in this community.