Hospital admissions and readmissions for asthma in the age group 0-4 years

Factors associated with future hospitalization among children with asthma: a systematic review

OBJECTIVE

Asthma is a leading cause of emergency department (ED) visits and hospitalizations in children, though many could be prevented. Our study objective was to identify factors from the published literature that are associated with future hospitalization for asthma beyond 30 days following an initial asthma ED visit.

DATA SOURCES

We searched CINAHL, CENTRAL, MEDLINE, and Embase for all studies examining factors associated with asthma-related hospitalization in children from January 1, 1992 to February 7, 2022.Selecting Studies: All citations were reviewed independently by two reviewers and studies meeting inclusion criteria were assessed for risk of bias. Data on all reported variables were extracted from full text and categorized according to identified themes. Where possible, data were pooled for meta-analysis using random effects models.

RESULTS

Of 2262 studies, 68 met inclusion criteria. We identified 28 risk factors and categorized these into six themes. Factors independently associated with future hospitalization in meta-analysis include: exposure to environmental tobacco smoke (OR = 1.94 95%CI 0.67-5.61), pets exposure (OR = 1.67 95%CI 1.17-2.37), and previous asthma hospitalizations (OR = 3.47 95% CI 2.95-4.07). Additional related factors included previous acute care visits, comorbid health conditions (including atopy), allergen exposure, severe-persistent asthma phenotype, inhaled steroid use prior to ED visit, poor asthma control, higher severity symptoms at ED presentation, warmer season at admission, longer length of stay or ICU admission, and African-American race/ethnicity.

CONCLUSIONS

We identified multiple factors that are consistently associated with future asthma hospitalization in children and could be used to identify those who would benefit from targeted preventative interventions.

Grass pollen exposure is associated with higher readmission rates for pediatric asthma

BACKGROUND

Pediatric asthma hospital readmission is a burden on the individual and costly for Australian hospitals. Grass pollen's role, a known trigger for asthma admissions, is unexamined in readmissions. We examined the association between grass pollen and pediatric asthma readmission.

METHODS

The Victorian Admitted Episodes Dataset was used to identify all primary admissions with a principal diagnosis of asthma in children aged 2-18 years between 1997 and 2009. Readmissions were defined as subsequent admissions within 28 days of index admission discharge. Generalized additive models were used to assess associations between readmission, grass pollen season, and daily grass pollen counts, lagged and cumulative. Models were further stratified by sex and age group.

RESULTS

Mean daily readmission was higher during grass pollen season than other times of the year, incidence rate ratio (IRR) 1.44 (95% CI, 1.03, 2.02) and for children aged 2-5 years, IRR 1.99 (1.26, 3.14). Same day grass pollen was nonlinearly associated with daily readmission for the 13-18 age group between 110 and 256 grains/m³ , p < .01. Lag 2 grass pollen was nonlinearly associated with daily readmissions overall (p = .03), boys (p = .01), and younger age groups 2-5 (p = .02) and 6-12 (p < .001).

CONCLUSIONS

Grass pollen exposure was associated with higher readmission rates for pediatric asthma. Treatment plans prior to discharge could be implemented to reduce the likelihood of readmission by younger children during the pollen season.

Risk Factors for Pediatric Asthma Readmissions: A Systematic Review

OBJECTIVE

To systematically review the literature on pediatric asthma readmission risk factors.

STUDY DESIGN

We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk.

RESULTS

Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4).

CONCLUSIONS

Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions.

TRIAL REGISTRATION

CRD42018107601.

Hospitalization, Asthma Phenotypes, and Readmission Rates in Pre-school Asthma

Objective: Children with pre-school asthma suffer disproportionally more often from severe asthma exacerbations with emergency visits and hospital admissions compared to school children. Despite this high disease burden, there are only a few reports looking at this particular severe asthma cohort. Similarly, there is little real-life research on the distribution of asthma phenotypes and personalized treatment at discharge in this age group. Patients and Methods: Retrospective analysis of the electronic charts of all children aged 1-5 years with asthma hospitalizations (ICD J45) at the Frankfurt University between 2008 and 2017. An acute severe asthma exacerbation was defined as dyspnea, oxygen demand, and/or systemic steroid therapy. Age, gender, duration of hospitalization, asthma phenotype, treatment, and readmission rate were analyzed. Results: Of 572 patients, 205 met the definition of acute severe asthma. The phenotypic characterization showed 56.1% had allergic asthma, 15.2% eosinophilic asthma and 28.7% non-allergic asthma. Of these patients, 71.7% were discharged with inhaled corticosteroids (ICS) or ICS + long-acting-beta-agonists (LABA), 15.1% with leukotriene antagonists (LTRA) and 7.3% salbutamol on demand. The rate of emergency presentations (emergency department and readmission) within 12 months after discharge was high (n = 42; 20.5%). No phenotype tailored treatment was detectable. Neither the number of eosinophils (>300/μl) nor the treatment at discharge had an effect on emergency visits and readmission rate. Conclusion: Despite protective therapy with ICS, ICS + LABA, or LTRA, the readmission rate was high. Thus, current care and treatment strategies should be reevaluated continuously, in order to better control asthma in pre-school children and prevent hospitalization.

National estimates of 30-day readmissions among children hospitalized for asthma in the United States

OBJECTIVE

Previous single-center studies have reported that up to 40% of children hospitalized for asthma will be readmitted. The study objectives are to investigate the prevalence and timing of 30-day readmissions in children hospitalized with asthma, and to identify factors associated with 30-day readmissions.

METHODS

Data (n = 12,842) for children aged 6-18 years hospitalized for asthma were obtained from the 2013 Nationwide Readmission Database (NRD). The primary study outcome was time to readmission within 30 days after discharge attributable to any cause. Several predictors associated with the risk of admission were included: patient (age, sex, median household income, insurance type, county location, and pediatric chronic complex condition), admission (type, day, emergency services utilization, length of stay (LOS), and discharge disposition), and hospital (ownership, bed size, and teaching status). Cox's proportional hazards model was used to identify predictors.

RESULTS

Of 12,842 asthma-related index hospitalizations, 2.5% were readmitted within 30-days post-discharge. Time to event models identified significantly higher risk of readmission among asthmatic children aged 12-18 years, those who resided in micropolitan counties, those with >4-days LOS during index hospitalization, those who were hospitalized in an urban hospital, who had unfavorable discharge (hazard ratio 2.53, 95% confidence interval 1.33-4.79), and those who were diagnosed with a pediatric complex chronic condition, respectively, than children in respective referent categories.

CONCLUSION

A multi-dimensional approach including effective asthma discharge action plans and follow-up processes, home-based asthma education, and neighborhood/community-level efforts to address disparities should be integrated into the routine clinical care of asthma children.

Risk factors associated with hospital readmission in pediatric asthma

Asthma is a leading cause of hospitalization among children, and about 15-50% of pediatric patients are readmitted after an index admission. The purpose of this integrative review is to explore contemporary scientific findings on the association between pediatric asthma readmission and various demographic, environmental, psychosocial and clinical risk factors. An electronic database search resulted in a sample of 29 studies. African American, public or no insurers, previous admission and complex chronic comorbidity were identified as risk factors associated with pediatric asthma readmission. However, more interdisciplinary and well-designed investigations are warranted to further explicate the spectrum of environmental and psychosocial correlates.

Bedroom air quality and vacuuming frequency are associated with repeat child asthma hospital admissions

OBJECTIVE

Indoor environment factors have been associated with risk of asthma exacerbations in children but little is known about their role on asthma hospital readmissions. As children in Western societies continually spend more time indoors, understanding the influence of these factors on asthma exacerbation is important. We examined the role of indoor environmental and lifestyle characteristics on child asthma readmissions.

METHODS

A hospital-based case-control study recruited 22 children readmitted for asthma and 22 controls not readmitted for asthma. Logistic regression models were used to examine the association between aeroallergens and fungi in the bedroom and indoor lifestyle characteristics factors for asthma readmissions. To determine the best possible set of predictors among a large set of risk factors, we used random forests (RF) techniques.

RESULTS

Higher levels of airborne Cladosporium and yeast in the child's bedroom increased risk of readmission (OR = 1.68, 95% CI 1.04-2.72 and OR = 1.52, 95% CI 0.99-2.34, respectively). Carpeted floors in the bedroom and synthetic doonas were also associated with increase in asthma readmissions (OR = 4.07, 95% CI 1.03-16.06 and OR = 14.6, 95% CI 1.26-169.4, respectively). In the home, frequent vacuuming using bagged cleaners increased risk of asthma readmission OR = 15.7 (95% CI 2.82-87.2).

CONCLUSIONS

Factors in the child's bedroom play an important role in increasing the risk of asthma hospital readmissions. These findings have major clinical implications as the identified potential risk factors may be modifiable. Further epidemiological studies with larger samples are necessary to evaluate these associations further.

Readmissions among children previously hospitalized with pneumonia

BACKGROUND AND OBJECTIVES

Pneumonia is a leading cause of hospitalization and readmission in children. Understanding the patient characteristics associated with pneumonia readmissions is necessary to inform interventions to reduce avoidable hospitalizations and related costs. The objective of this study was to characterize readmission rates, and identify factors and costs associated with readmission among children previously hospitalized with pneumonia.

METHODS

Retrospective cohort study of children hospitalized with pneumonia at the 43 hospitals included in the Pediatric Health Information System between January 1, 2008, and December 31, 2011. The primary outcome was all-cause readmission within 30 days after hospital discharge, and the secondary outcome was pneumonia-specific readmission. We used multivariable regression models to identify patient and hospital characteristics and costs associated with readmission.

RESULTS

A total of 82 566 children were hospitalized with pneumonia (median age, 3 years; interquartile range 1-7). Thirty-day all-cause and pneumonia-specific readmission rates were 7.7% and 3.1%, respectively. Readmission rates were higher among children <1 year of age, as well as in patients with previous hospitalizations, longer index hospitalizations, and complicated pneumonia. Children with chronic medical conditions were more likely to experience all-cause (odds ratio 3.0; 95% confidence interval 2.8-3.2) and pneumonia-specific readmission (odds ratio 1.8; 95% confidence interval 1.7-2.0) compared with children without chronic medical conditions. The median cost of a readmission ($11 344) was higher than that of an index admission ($4495; P = .01). Readmissions occurred in 8% of pneumonia hospitalizations but accounted for 16.3% of total costs for all pneumonia hospitalizations.

CONCLUSIONS

Readmissions are common after hospitalization for pneumonia, especially among young children and those with chronic medical conditions, and are associated with substantial costs.

Rehospitalization for childhood asthma: timing, variation, and opportunities for intervention

OBJECTIVE

To assess the timing of pediatric asthma rehospitalization, variation in rate of rehospitalization across hospitals, and factors associated with rehospitalization at different intervals.

STUDY DESIGN

Retrospective cohort analysis of 44,204 hospitalizations for children with asthma within 42 children's hospitals between July 2008 and June 2011. The main outcome measures were rehospitalization for asthma within 7, 15, 30, 60, 180, and 365 days of an index asthma admission.

RESULTS

The rate of asthma rehospitalization ranged from 0.5% (n = 208) at 7 days to 17.2% (n = 7603) at 365 days. Black patients and patients with public insurance had higher odds of rehospitalization at 60 days and beyond (P ≤ .01 for both). Adolescents (12- to 18-year-old), patients with a diagnosis of a complex chronic condition, and patients with a prior year asthma admission had higher odds of rehospitalization at every time interval (P ≤ .001 for all). Significant hospital variation in case-mix adjusted rates of rehospitalization existed at each time interval (P ≤ .01 for all). Rates at 365 days were ≤ 10.9% for the top 10% of hospitals; if all hospitals achieved this rate, 36.6% of rehospitalizations might have been avoided.

CONCLUSIONS

Significant variation in asthma rehospitalization rates exists across children's hospitals from 7 to 365 days after an index admission. Racial/ethnic and economic disparities emerge at 60 days. By 1 year, rehospitalizations account for 1 in 6 hospitalizations. Assessing asthma rehospitalizations at longer intervals may augment our current understanding of and approach to post-hospitalization care improvement.

Predictors of hospital admission due to asthma in children and adolescents enrolled in an asthma control program

OBJECTIVE

To determine the clinical characteristics and the predictors of hospital admission due to asthma among children and adolescents with asthma under treatment at a referral center.

METHODS

A retrospective cohort study comprising 151 children and adolescents with asthma, referred from the Unified Health Care System and enrolled in the Asthma and Allergic Rhinitis Control Program in the city of Feira de Santana, Brazil, followed for a period of 12 months and receiving asthma medication at no cost. The chi-square test was used in order to determine the associations between the studied variables and the occurrence of hospital admissions, whereas the Mann-Whitney test was used for the comparison between the groups of hospitalized patients and nonhospitalized patients. The level of significance was set at p < 0.05. Univariate analysis with logistic regression was performed in order to determine the predictors of hospital admission.

RESULTS

Of the 151 patients evaluated, 8 (5.2%) were hospitalized, in a total of 12 hospital admissions. In the univariate analysis, the only variable found to be a predictive factor was greater asthma severity (OR = 13.3; 95% CI: 2.55-70.1).

CONCLUSIONS

The fact that, in our study sample, the principal predictor of hospital admission was greater asthma severity, calls for special attention being given to the care of these patients.

Asthma medication use in infancy: determinants related to prescription of drug therapy

BACKGROUND

Little is known about factors that determine prescribing of asthma therapy in infancy.

OBJECTIVE

To describe factors related to the initiation and refill of asthma therapy in infancy.

METHODS

This study included 1202 infants who participated in a prospective birth cohort study: the 'Wheezing Illnesses Study Leidsche Rijn (WHISTLER)'. Outcomes, asthma therapy initiation and refill, were assessed using prescription data. Logistic regression analysis was used to study determinants of therapy initiation in two groups: total population and infants with a respiratory system symptom diagnosis. In addition, determinants of refilling prescriptions were studied in infants who started therapy in their first year of life.

RESULTS

Fifteen per cent of all infants started asthma therapy in their first year of life. Respiratory symptoms were an important driver of both initiation and refill of prescriptions. In the total population, therapy initiation was associated with male gender [odds ratio (OR): 1.6, 95% confidence interval (CI): 1.1-2.6], day-care attendance (OR: 1.6, 95% CI: 1.0-2.5) and breastfeeding (OR: 0.6, 95% CI: 0.3-1.0). For infants with a respiratory system symptom diagnosis, day-care attendance was associated with an increased chance of therapy initiation (OR: 5.3, 95% CI: 1.8-16.2) and breastfeeding was associated with a lower chance of starting therapy (OR: 0.4, 95% CI: 0.1-1.1). Dutch children had a higher chance of refilling prescriptions in infancy (OR: 5.3, 95% CI: 1.1-26.8).

CONCLUSIONS

Apart from other factors involved, the principal reason for initiation and refill of asthma therapy in infancy was the presence of respiratory symptoms. This appeared the only reason to prescribe medication and physicians are not distracted by other factors.

Regional and racial disparities in asthma hospitalizations in Mississippi

BACKGROUND

In the United States, asthma hospitalization rates are disproportionately high among blacks compared with other racial/ethnic groups and vary by geographic region. These disparities among asthma hospitalizations might be affected by social, environmental, and health-care access factors.

OBJECTIVE

To determine demographic risk factors for asthma hospitalizations in urban versus rural areas of Mississippi.

METHODS

A cross-sectional study using data from the Mississippi Asthma Surveillance System was conducted to compare asthma hospitalizations in the urban Jackson metropolitan statistical area and rural Delta regions of Mississippi from 2003 to 2005. Factors including race, sex, age, and household income that might be associated with multiple hospitalizations for asthma (3 or more during the study period) were assessed using logistic regression.

RESULTS

Asthma hospitalization rates were significantly higher among all demographic groups in the rural Delta region compared with the urban Jackson Metropolitan Statistical Area (P < .001). In both regions, hospitalization rates were higher among blacks and females (P < .001). Asthma hospitalization rates were highest among children (0-17 years) and older adults (>or=65 years). In both regions, blacks were more likely to have 3 or more asthma hospitalizations (P < .001). Residents of the Delta had higher odds for multiple hospitalizations controlling for race, sex, age, and household income (P < .05).

CONCLUSION

Blacks with asthma are more likely to have multiple asthma hospitalizations in Mississippi. Higher odds of multiple asthma discharges for Delta residents were not explained by race, sex, age, or income, indicating that other contributing factors (eg, environmental, social, and access to care factors) need further investigation.

Respiratory symptoms in young infancy: child, parent and physician related determinants of drug prescription in primary care

PURPOSE

Respiratory symptoms account for the majority of drug prescriptions in the first year of life. We investigated the influence of child, parent and physician factors on drug prescriptions for respiratory symptoms in primary care in infancy.

METHODS

Infants participated in the WHeezing Illnesses STudy LEidsche Rijn (WHISTLER), a prospective birth cohort on respiratory illnesses. Outcome was defined as having received a prescription of antibiotics or of anti-asthma medication for respiratory symptoms by a physician.

RESULTS

Nearly 60% of all children ever visited a physician for respiratory symptoms during the first year of life, of which 40% received a prescription. Every extra day with symptoms during the month before consultation and each extra visit to a physician were associated with a higher chance for prescription (respectively odds ratios (OR) 1.07/2.63, 95% confidence intervals (CI) 1.02-1.12/1.83-3.76). Further, we found a higher chance for drug prescribing for boys (2.7, 2.0-3.7), children attending day care (1.17, 1.09-1.25), mothers with higher education (2.3, 1.2-4.6), working mothers (4.5, 0.9-22.0) and older mothers (years) (1.09, 1.02-1.16). Furthermore, physicians' years of experience was a determinant for receiving a prescription (2.5, 1.1-6.0). Accounting for symptoms and visits as strong predictors of prescribing, infant gender and day care attendance were still predictors. Furthermore, infant gender, day care attendance, family history of asthma and physicians' years of experience were independent determinants of the number of prescriptions besides symptoms and visits.

CONCLUSION

In young infancy, besides the severity of symptoms there are child, physician and particularly maternal characteristics that influence the decision of general practitioners to prescribe drugs for respiratory symptoms.

Use of inhaled corticosteroids decreases hospital admissions for asthma in young children

BACKGROUND

An active use of inhaled corticosteroids for asthma has been associated with less asthma exacerbations and hospital admissions in children aged more than 2 years. The present study aimed to investigate hospital admission rates in young children from two populations in relation to the age-specific use of maintenance medication for asthma.

METHODS

Annual data on children aged less than 24 months treated for asthma, including data on the use of maintenance medication based on the purchases of prescribed medications, and annual numbers of admissions to hospital and proportions of readmissions, were collected from 1995 to 1999 in two provinces of Finland. The inclusion criteria, three or more doctor-diagnosed wheezing episodes, were individually checked by the authors in each case. The mean number of children aged less than 24 months during the years of the study was 5490 in Kuopio and 9914 in Oulu area.

RESULTS

In the Kuopio area, during the years of the study, 16.5/1000 children aged less than 24 months were on maintenance medication for asthma, and 90% of them were receiving inhaled corticosteroids. In the Oulu area, the respective figures were 13.5/1000 (P<0.001) and 99%. The average admission rate was 7.9/1000 in the Kuopio area and 8.7/1000 in the Oulu area (P<0.05). The readmissions indicated the higher admission rates in the Oulu (40% of all admissions) than in the Kuopio (28%) area (P<0.01).

CONCLUSION

Active use of maintenance therapy by inhaled corticosteroids was associated with a decreased need of hospital treatment in young children <24 months old with asthma, mainly because of less readmissions.

Pharmaceutical treatment strategies for childhood asthma

PURPOSE OF REVIEW

Although great improvement has been obtained in quality of life and mastering of illness by asthmatic children over recent decades, controversies still exist related to asthma treatment. The objective of the present article is to discuss such controversies.

RECENT FINDINGS

Results from recent publications related to childhood asthma treatment question existing dogmas. Important for prescribing correct treatment to children is correct diagnosis. Phenotypes of childhood asthma related to treatment decisions are discussed. Early use of inhaled steroids in young children is still debated as well as the preference of inhaled long-acting beta2-agonists versus leukotriene receptor antagonists as add on to inhaled steroids. When present, both allergic rhinitis and asthma should be treated to obtain improved control. Also as regards the treatment of exercise-induced asthma in children, new results concerning use of leukotriene receptor antagonists is discussed as well as the acute treatment in infants with bronchial obstruction.

SUMMARY

There are still several controversies regarding treatment of the asthmatic child. New studies designed specifically for children are needed to solve these questions. One cannot rely on studies performed in adults for treatment in children. New studies designed for childhood asthma are needed to solve these controversies.

Risk factors leading to hospital admission in Iranian asthmatic children

BACKGROUND

Asthma is one of the most common chronic diseases in the world, leading to an increased rate of hospitalization. We performed this study to better understand the factors leading to admission among asthmatic children.

METHODS

We performed a study among asthmatic children in a referral hospital for asthma and allergy in Tehran. Sixty-three cases were selected from asthmatic children admitted to the emergency room (ER) who still had an indication for ward or intensive care unit admission after primary treatment. Our control group was the asthmatic children discharged after primary treatment and patients who were referred to the asthma and allergy clinic (63 patients). Data were obtained by structured questionnaires filled out during clinical interviews.

RESULTS

There was a significant difference in mean age (5 years for cases vs. 6 years for controls; p = 0.049), personal and familial allergic history (69.8 and 57.1% for cases vs. 34.9 and 36.5% for controls; p < 0.01 and p = 0.02, respectively), history of recent respiratory infections (79.4% for cases vs. 49.2% for controls; p < 0.01), hospitalization history due to asthma (57.1% for cases vs. 23.8% for controls; p < 0.01) and regular use of inhaled corticosteroid (66.7% for cases vs. 33.3% for controls; p < 0.01).

CONCLUSIONS

Our findings confirm most previous observations, suggesting that recent respiratory infections, hospitalization, personal or familial allergy, disease severity and lower ages are important factors leading to hospitalization. We also found that regular clinical follow-up, regular use of inhaled corticosteroids, higher IgE levels and O2 saturation may lower the probability of hospitalization during asthmatic attacks.

Determinants of health care utilization for respiratory symptoms in the first year of life

OBJECTIVE

Health care utilization for respiratory symptoms is very common in infancy. Little is known about the determinants of visiting a physician for such complaints in infants. We investigated which factors determine the likelihood of visiting a physician for respiratory symptoms in the first year of life of their offspring.

PATIENTS AND METHODS

Infants were participants of the ongoing Wheezing Illnesses Study Leidsche Rijn (WHISTLER), a prospective birth cohort study on respiratory illnesses. Parental reports on respiratory symptoms and possible risk factors were assessed by daily questionnaires. Physician diagnosed respiratory symptoms were classified in medical records using the International Classification of Primary Care. Outcome was defined as a having a child visit a general practitioner for respiratory symptoms in the first year of life. Logistic regression was used to study the likelihood of outcome (yes/no) as a function of putative predictors.

RESULTS

Forty-seven percent of the infants visited a physician for respiratory symptoms in the first year of life. Every extra week of respiratory symptoms was associated with a 4.3% higher chance (odds ratio [OR], 1.043; 95% confidence interval [CI], 1.022-1.065) of visiting a physician. Furthermore, the chance was higher in boys (OR, 1.5; 95% CI, 1.1-2.1), children attending day care (OR, 1.9; 95% CI, 1.2-3.0), children with nonwhite mothers (OR, 1.9; 95% CI, 1.1-3.2), and children whose mother had supplementary health care insurance (OR, 1.7; 95% CI, 1.1-2.7). Findings were similar within the subgroup of children with serious respiratory symptoms (>median: 46 d/yr), but in that group parental age over 30 also determined physician visits (OR, 3.8; 95% CI, 1.6-8.9).

CONCLUSIONS

Child and parent characteristics, besides complaints per se, play an important role in health care utilization for respiratory illnesses in infancy.

Asthma hospitalizations among American Indian and Alaska Native people and for the general US population

STUDY OBJECTIVES

Asthma is one of the most common chronic diseases in the United States. High rates of asthma hospitalization have been reported for some ethnic minorities; however, asthma hospitalization rates for American Indian/Alaska Native (AI/AN) populations of all ages have not been studied. In this study, we examined and compared hospitalization rates for AI/AN populations and the general population in the United States.

DESIGN

Hospital discharge records with a first-listed diagnosis of asthma were evaluated for AI/AN populations and the US general population of all ages from 1988 to 2002.

RESULTS

The asthma hospitalization rate for AI/AN populations decreased from 17.8/10,000 per year in 1988 to 1990 to 12.9/10,000 per year in 2000 to 2002. The overall age-adjusted rate for 2000 to 2002 was slightly lower than that for the general US population (12.9/10,000 and 16.4/10,000, respectively). However, AI/AN populations living in the Southwest region (17.6/10,000) had the highest asthma hospitalization rate among the Indian Health Service regions and the rate from 2000 to 2002 was similar to that for the general US population. The 2000 to 2002 asthma hospitalization rate for AI/AN populations < 1 year of age (infants) was higher than that in US infants, and the rates for AI/AN age groups > or = 1 year were similar to or lower than those for the general US population.

CONCLUSIONS

While asthma was rarely reported among AI/AN populations before 1975, the average annual age-adjusted asthma hospitalization rate was only slightly lower for AI/AN populations than that for the US general population from 2000 to 2002. Furthermore, the asthma hospitalization rates for AI/AN populations living in the Southwest and East regions were similar to the rate for the general US population. Efforts to further increase asthma awareness and symptom recognition among AI/AN populations should be implemented to help to reduce asthma hospitalizations.

Fatores de risco para readmissão hospitalar de crianças e adolescentes asmáticos

OBJETIVO: Verificar a importância da admissão hospitalar de lactentes jovens na readmissão futura por asma. MÉTODOS: Realizou-se uma avaliação retrospectiva de prontuários de 202 pacientes, menores de quinze anos, registrados em ambulatório de Pneumologia Pediátrica, que foram reinternados uma ou mais vezes. O tempo decorrido entre a primeira hospitalização e a subseqüente readmissão foi analisado pelo método de Kaplan Meier, ao passo que a comparação entre as curvas de sobrevivência para diferentes faixas etárias foi analisada pelo teste log-rank. Empregou-se ainda análise multivariada para avaliação dos fatores de risco associados à readmissão. RESULTADOS: Readmissões foram observadas na quase totalidade dos pacientes nos dezoito meses seguintes à primeira hospitalização (94,5%). Quando a idade à primeira admissão hospitalar foi =12 meses, a readmissão foi mais precoce, comparada à do grupo com doze meses ou mais (p = 0,001). Os fatores de risco associados à readmissão foram: idades à primeira admissão inferiores a doze meses (odds ratio: 2,55, intervalo de confiança de 95%: 1,18 - 5,48) e entre treze e 24 meses (odds ratio: 3,54, intervalo de confiança de 95%: 1,31 - 9,63), e gravidade do quadro clínico de asma (odds ratio: 3,86, intervalo de confiança de 95%: 2,02 - 7,4). CONCLUSÃO: Após a primeira hospitalização, as crianças com asma devem ter acompanhamento rigoroso, pois o risco de readmissão é elevado nos primeiros meses após a alta, principalmente nos menores de dois anos. Os serviços de saúde devem se organizar adequadamente para enfrentar este problema, inclusive quanto à ampla dispensação de medicação profilática.

Outcome evaluation of early discharge after hospitalization for asthma

PURPOSE OF REVIEW

This review is designed to assess the evidence around the criteria used to decide when it is appropriate for an individual with asthma to be discharged from hospital.

RECENT FINDINGS

There has been scanty recent published research on this subject, and no strong evidence-based discharge guidelines exist. The limited data available suggest that clinical outcome in children is similar when the timing of discharge is the need for 3-hourly rather than 4 hourly bronchodilator. In children, the adoption of this policy would shorten the average length of hospital stay by 5-6 h.

SUMMARY

The available data for adults with acute asthma on the appropriate end points for discharge from hospital are inadequate to provide firm conclusions. Children with acute asthma should be considered ready for discharge when clinically stable on 3-hourly bronchodilator.

Asma em menores de cinco anos: dificuldades no diagnóstico e na prescrição da corticoterapia inalatória

O objetivo deste trabalho foi fazer um levantamento bibliográfico focalizando as dificuldades para se diagnosticar a asma e se estabelecer o início da corticoterapia inalatória em menores de cinco anos. As fontes pesquisadas foram as bases de dados LILACS e MEDLINE, no período de 1991 a 2002, em português, espanhol e inglês. A asma, doença crônica mais comum na infância, apresenta o início dos sintomas nos primeiros anos de vida em grande percentagem dos casos. Na atualidade, não existem meios propedêuticos disponíveis rotineiramente que permitam estabelecer com certeza o diagnóstico em menores de cinco anos. De acordo com as manifestações clínicas, lactentes e pré-escolares podem demandar tratamento semelhante ao da asma desde que precedido por avaliação clínica criteriosa. Conclui-se que o diagnóstico da asma nos primeiros anos de vida é complexo e eminentemente clínico. A corticoterapia inalatória constitui recurso eficaz, mas exige ponderação dos riscos e benefícios.

Trends in asthma prevalence, hospitalization risk, and inhaled corticosteroid use among alaska native and nonnative medicaid recipients younger than 20 years

BACKGROUND

Few trend data on asthma prevalence exist for U.S. indigenous populations, and none exist for Alaska Natives.

OBJECTIVE

To document the epidemiologic features of asthma in Alaska Natives and nonnatives stratified by urban (Anchorage) and rural (non-Anchorage) residence.

METHODS

We conducted a retrospective review of Alaskans younger than 20 years enrolled in Medicaid during 1999 to 2002. Asthma was defined as a claim for International Classification of Diseases, Ninth Revision, codes 493.0x to 493.9x plus asthma-associated medication during the same calendar year.

RESULTS

Among 117,080 Medicaid enrollees, the 4-year asthma prevalence was 3.1% and was 40% to 90% greater for urban residents regardless of race. Yearly prevalence increased from 1.0% to 2.2% (P < .001), with increases in all subgroups. Of 4 predominantly Alaska Native census areas, the area with resident pediatricians and previous participation in asthma research had a 4-year asthma prevalence 5- to 11-fold higher than the other areas. Among persons with asthma, yearly hospitalization risk decreased (from 9.3% to 6.8%; P = .02) concurrent with an increase in the yearly use of inhaled corticosteroids (from 50% to 64%; P < .001). Urban Alaska Natives had the greatest decrease in hospitalization risk and the greatest increase in inhaled corticosteroid use.

CONCLUSIONS

Relatively dramatic demographic differences and temporal trends in asthma prevalence occurred in the absence of known differences or changes in risk factor prevalences. This suggests a role for differences in the use of asthma as a diagnosis for respiratory illness. Failure to diagnose and thus treat asthma may affect outcomes because decreases in hospitalization risk were temporally associated with increases in inhaled corticosteroid use.

A retrospective population based trend analysis on hospital admissions for lower respiratory illness among Swedish children from 1987 to 2000

BACKGROUND

Data relating to hospital admissions of very young children for wheezing illness have been conflicting. Our primary aim was to assess whether a previous increase in hospital admissions for lower respiratory illness had continued in young Swedish children. We have included re-admissions in our analyses in order to evaluate the burden of lower respiratory illness in very young children. We have also assessed whether changes in the labelling of symptoms have affected the time trend.

METHODS

A retrospective, population based study was conducted to assess the time trend in admissions and re-admissions for lower respiratory illness. Data were obtained from the Swedish Hospital Discharge Register for all children with a first hospital admission before nine years of age, a total of 109,176 children. The register covers more than 98% of all hospital admissions in Sweden. The coding of diagnoses was based on ICD-9 from 1987 to 1996 and ICD-10 from 1997.

RESULTS

The first admission rates declined significantly in children with a first admission after two years of age. However, an increasing admission trend was observed in children aged less than one year and 35% of first admissions occurred in this age group. The annual increase was 3.8% (95% CI 1.3-6.3) in boys and 5.0% (95% CI 2.4-7.6) in girls. A diagnostic shift appeared to occur when ICD-10 was introduced in 1997. The asthma and pneumonia admission rate in children aged less than one year levelled off, whereas the increase in admissions for bronchitis continued. The re-admission rates for asthma decreased and the probability of re-admission was higher in boys. National drug statistics demonstrated a substantial increase in the delivery of inhaled steroids to all age groups but most prescriptions occurred to children aged one year or more.

CONCLUSION

Hospital admissions for lower respiratory illness are still increasing in children aged <1 year. Our findings are in line with other recent studies suggesting a change in the responsiveness to viral infections in very young children, but changes in admission criteria cannot be excluded. An increased use of inhaled steroids may have contributed to decreasing re-admission rates.