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OBJECTIVES: To evaluate the impact of vaccination for Haemophilus influenzae type b (Hib) on pediatric hospital admissions in New York State, and to identify risk factors in children who continue to be admitted for Hib invasive disease. METHODS: Retrospective review of hospitalizations in New York state from 1982 through 1993 and a survey of immunization records from physician offices in Monroe Country, New York. RESULTS: In 1982, 769 children were admitted to New York state hospitals for Hib-related conditions; by 1993, this had decreased to 133. Significant declines during the study period occurred in the age-adjusted admission rates for Hib meningitis, septicemia, pneumonia, and epiglottitis, but not for arthritis and osteomyelitis. In 1993 alone, 712 admissions, 18 deaths, and 135 episodes of morbidity were avoided. Since 1991, the rates of admissions for Hib-related conditions have remained fairly constant. Minority subjects continue to be twice as likely as white subjects to be admitted for invasive Hib disease (0.44 vs 0.17/100,000). Children living in urban Rochester also are more likely to be admitted and less likely to be completely immunized against Hib (61%) than those living in suburban areas (82%). CONCLUSIONS: Although Hib vaccine has had a major impact on hospital admissions for Hib-related conditions, the goal of completely eliminating Hib disease will require programs targeted at groups at high risk, such as minorities and those living in cities.

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OBJECTIVE: Lower respiratory tract illness (LRI) is the most common serious illness in childhood and the most common reason for hospitalization of infants beyond the neonatal period. This study assessed the potential for cost savings from reduction in hospitalization for LRI. SETTING AND SAMPLE: LRI hospitalization rates for children in the first 2 years of life (infants) were studied for the 62 counties of New York State and six socioeconomic areas within Monroe County (Rochester) for the years 1985 through 1991. DESIGN: Analysis of small area variations. RESULTS: LRI accounted for 51.2% of infant hospitalizations in New York State. The overall LRI hospitalization rate for New York's 62 counties was 27.0 per 1000 child-years and ranged, among the 18 most populous counties, from 10.7 for Monroe County to 39.3 for the Bronx. Unemployment rate was the strongest predictor of LRI hospitalization rates for counties, explaining 29% of the variance in multiple regression analysis. Within Monroe County, LRI hospitalization rates followed a geographic gradient from the inner city (22.5) to the rest of the city (12.2), and to the suburbs (7.3). Deaths from LRI were uncommon (0.36% of state LRI hospitalizations) and varied little between inner city (0.42%) and suburbs (0.51%). If LRI hospitalization rates for Monroe County suburban children prevailed for the entire state, 10,439 hospitalizations and $32,916,000 would be saved annually. CONCLUSIONS: A large portion of the increased cost of health care for children living in poverty is attributable to hospitalization for LRI in infants. Physician discretion in decision making and factors associated with socioeconomic status are probably major determinants of variation. Well-coordinated follow-up of acute illness visits, home monitoring by visiting nurses, and empirically based clinical guidelines for management of LRI might yield both substantial cost savings and better service to families.

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We produced and tested rules to predict undervaccination among preschool-age emergency department (ED) patients. Data were gathered on demographics, vaccination status, health status, and health care utilization from parents, ED physicians, and ED charts at an urban teaching hospital in Rochester, N.Y. Primary care charts were reviewed to verify vaccination status. Using recursive partitioning, we developed decision rules to predict undervaccination. Decision rules were developed on a sample of 602 ED patients 4 to 48 months of age and then prospectively tested on 1832 ED patients aged 6 to 36 months. Factors associated with undervaccination for any vaccine included parental report of vaccination delay (odds ratio = 8.1; p < 0.001), inability to report the receipt of the appropriate number of vaccines (odds ratio = 4.5; p < 0.001), lack of health insurance (odds ratio = 3.6, p < 0.001), elapsed time since the last visit to primary care provider (p < 0.001), household size (p < 0.001), and maternal age (p < 0.01). Eight decision rules were produced that varied in their number of questions (one to six), sensitivity (0.27 to 0.87), and specificity (0.54 to 0.98). No single rule was both highly sensitive and highly specific. The rules' sensitivities and specificities were similar for the validation sample of 1832 patients. Thus a decision rule could not be produced that was both sensitive and specific. Identification of undervaccinated children by means of information available at an ED visit is inherently difficult. Interventions in the ED may be inefficient unless better methods of assessing vaccination status can be developed.

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Two major subtypes of respiratory syncytial virus have been identified. This study assessed the hypothesis that A-subtype infections were more severe than B-subtype infections among the 157 infants hospitalized in two hospitals in Rochester, N.Y., during two winters. Severity was measured both by specific clinical observations and by a severity index that was derived empirically. Among all subjects, several clinical observations suggested that A-subtype infections were more severe. For example, mechanical ventilation was required in 12.6% of those with A-subtype compared with 1.6% of those with B-subtype infection (relative risk = 7.88; p = 0.01). Among high-risk infants (infants with underlying conditions or age 3 months or less at admission), carbon dioxide tension greater than 45 mm Hg was found in 37.0% of those with A-subtype compared with 12.0% of those with B-subtype infection (relative risk = 3.08; p = 0.04). In discrete multivariate (logit) analysis, effects of subtype (odds ratio = 6.59; p less than 0.01) on severity remained after adjustment for other statistically significant effects of age less than 3 months, underlying condition, and premature birth. The finding that A-subtype infections were more severe might have important implications for vaccine development, studies of the virulence of respiratory syncytial virus, clinical management (e.g., selection for antiviral therapy), and long-term prognosis.

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A controlled clinical trial comparing early closure (mean = 48.8 hours) of the patent ductus arteriosus using indomethacin to conventional medical management, with intervention only after cardiopulmonary decompensation (mean = 167.4 hours), was undertaken in 24 preterm infants with severe respiratory distress syndrome and evidence of PDA. An interval analysis of one-half the projected sample revealed that infants undergoing early closure of the PDA had significantly reduced occurrence of BPD or mortality by 6 months of age. A comparison of birth weight, Apgar scores, gestational age, age of initial PDA diagnosis, and fluid therapy during the first seven days of life showed no significant differences between early intervention and control groups. At the time of the interval analysis, there were no differences between the groups in duration of intermittent mandatory ventilation or oxygen exposure. Studies will be required to determine whether these and other variables can be altered by early closure of the PDA.

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