Child day care risks of common infectious diseases revisited

BACKGROUND: The increased risk of common infectious diseases associated with child day care attendance may vary by age, health plan and parent educational level. This study determined quantitatively the risk of diarrhoeal illness and upper respiratory infection (URI) among day-care children in comparison with home-care children. It examined the extent of risks in day-care children under different conditions of three age groups, enrolled in two health plans, and from families of two levels of education. METHODS: The study subjects were recruited through two health plans: a Health Maintenance Organization (HMO) and the Medicaid program in Columbia, South Carolina of the USA. The sample was collected using a household survey of children, aged 5 years or younger. The participants were contacted bimonthly for 18 months with 435 attending out-of-home day care facilities and 753 being cared for at home. The potential confounding factors of family characteristics were controlled in examining the odds ratios for day care effect on common infections in children under different conditions. RESULTS: In general, risks of diarrhoeal illness and URI in day-care children are greater than in home-care children. Children younger than 1.5 years of age attending day care and covered by the Medicaid program are at the greatest risk. The difference in risks between day-care and home-care children, however, is reduced to an insignificant level for children older than 1.5 years of age and for children covered by the HMO health plan. Among day-care children, those who are covered by the Medicaid program are at a significantly higher risk than those who are covered by the HMO health plan. CONCLUSIONS: Although day-care children in general suffer a greater risk of common infectious diseases, the extent of day care effect on risks of diarrhoeal illness and URI varies significantly by age and type of health insurance plan.     

Preliminary Assessment of Appropriateness of Emergency Care Service Use: Actions Taken and Consultations Obtained Before Emergency Care Presentation

Inappropriate use of emergency care services can increase hospital readmissions and related costs. This pilot, cross-sectional survey project determined whether home health care patients who receive emergency care services during a Medicare-approved home care episode sought consultation from health care professionals before they made the emergency care visit. The two research questions were: (a) What actions were taken by the patient before making an emergency care visit?; (b) If prior consultation was obtained, what were the suggestions? Preliminary data were obtained from a Michigan-based, Medicare-certified, not-for-profit home health agency affiliated with a university health system. A two-page questionnaire recorded up to three emergency care visits. Volunteer participants were Medicare patients who had no cognitive deficits and were able to communicate with home health care providers (HHCPs) by themselves. Thirty-five emergency care visits were reported; 31 (88.6%) Medicare patients participated and 4 (11.4%) of them had two emergency care visits. Before the patients made an emergency care visit, they most often called their primary care physicians (PCPs; N = 20, 57.1%), followed by the HHCPs (N = 10, 28.6%). All 20 patients who contacted their PCPs and 7 patients who contacted their HHCPs were advised to seek emergency care services. In 20 emergency care visits the patient was admitted for an acute hospital stay; the other 15 patients went home. Most patients contacted their PCPs or HHCPs before they went to an emergency department or urgent care facility. These results implied that PCPs and HHCPs seemed to perceive that the need for emergency care should be determined at an emergency room or urgent care facility. This study was unable to differentiate the need for emergency care services or the appropriateness of the advice given by PCPs or HHCPs when the home care patients were under the care of a medical team.     

Preliminary assessment of appropriateness of emergency care service use: actions taken and consultations obtained before emergency care presentation

Inappropriate use of emergency care services can increase hospital readmissions and related costs. This pilot, cross-sectional survey project determined whether home health care patients who receive emergency care services during a Medicare-approved home care episode sought consultation from health care professionals before they made the emergency care visit. The two research questions were: (a) What actions were taken by the patient before making an emergency care visit?; (b) If prior consultation was obtained, what were the suggestions? Preliminary data were obtained from a Michigan-based, Medicare-certified, not-for-profit home health agency affiliated with a university health system. A two-page questionnaire recorded up to three emergency care visits. Volunteer participants were Medicare patients who had no cognitive deficits and were able to communicate with home health care providers (HHCPs) by themselves. Thirty-five emergency care visits were reported; 31 (88.6%) Medicare patients participated and 4 (11.4%) of them had two emergency care visits. Before the patients made an emergency care visit, they most often called their primary care physicians (PCPs; N = 20, 57.1%), followed by the HHCPs (N = 10, 28.6%). All 20 patients who contacted their PCPs and 7 patients who contacted their HHCPs were advised to seek emergency care services. In 20 emergency care visits the patient was admitted for an acute hospital stay; the other 15 patients went home. Most patients contacted their PCPs or HHCPs before they went to an emergency department or urgent care facility. These results implied that PCPs and HHCPs seemed to perceive that the need for emergency care should be determined at an emergency room or urgent care facility. This study was unable to differentiate the need for emergency care services or the appropriateness of the advice given by PCPs or HHCPs when the home care patients were under the care of a medical team.     

Factors affecting decisions to seek treatment for sick children in Kerala,India

The purpose of this study was to measure the effects of social and economic variables, disease-related variables, and child gender on the decisions of parents in Kerala, India, to seek care for their children and on their choice of providers in the allopathic vs. the alternative system. A case-control analysis was done using data from the Kerala section of the 1996 Indian National Family Health Survey, a cross-sectional survey of a probability sample of households conducted by trained interviewers with a close-ended questionnaire. Of the 469 children who were eligible for this study because they had at least one common symptom suggestive of acute respiratory illness or diarrhea during the 2 weeks before the interview, 78 (17%) did not receive medical care, while the remaining 391 (83%) received medical care. Of the 391 children who received medical care, 342 (88%) received allopathic medical care, and 48 (12%) received alternative medical care. In multivariable analyses, parents chose not to seek medical care for their children significantly more often when the illness was mild, the child had a specific diagnosis, the mother had previously made fewer antenatal visits, and the family had a higher economic status. When parents sought medical care for their children, care was sought significantly more often in the alternative provider system when the child was a boy, the family lived in a rural area, and the family had a lower social class. We conclude that, in Kerala, disease severity and economic status predict whether children with acute respiratory infection or diarrhea are taken to medical providers. In contrast, most studies of this issue carried out in other populations have identified economic status as the primary predictor of medical system utilization. Also in Kerala, the gender of the child did not influence whether or not the child was taken for treatment but did influence whether care was sought in the alternative or the allopathic system.     

Use and perceptions of antibiotics for upper respiratory infections among college students

BACKGROUND: Upper respiratory infections (URIs) are mainly viral in nature, rendering antibiotics ineffective. Little is known about what college students believe concerning the effectiveness of antibiotics as a treatment for URIs. METHODS: Students (n=425) on 3 college campuses were surveyed using a survey describing 3 variations in presentation of an uncomplicated URI. Participants were questioned about their likelihood of using a variety of treatments for the URI and about their likelihood of seeking a physician's care. RESULTS: The percentage of students endorsing antibiotic use differed significantly by symptom complex. Likelihood of seeking medical care also differed significantly across symptom groups, with greater endorsement in the discolored nasal discharge and low-grade fever scenarios. Stepwise multiple regression analysis revealed that belief in antibiotic effectiveness for cold symptoms decreased with tic and Therapeutic increasing years of higher education. Likelihood of antibiotic use across different scenarios increased with age. Likelihood of seeking care across different scenarios was related to type of health insurance and belief in antibiotic effectiveness. CONCLUSIONS: Undergraduate college students show poor recognition of typical presentations of the common cold and have misconceptions about effective treatment. Although increasing years of college correlated with decreasing belief in antibiotics' effectiveness for a cold, more health education at the college level is recommended.     

A study of attitudes toward medical care and health behaviors among older adults

In order to understand the attitudes of older adults toward medical care, we interviewed 480 persons living in Yokohama, and 180 persons living in Aikawa, Kanagawa, aged 45 to 84 years old. The following results were obtained; 1) Attitudes toward medical care can be classified into four types; self-determined medical care, self treatment attitudes, high dependence on the medical care system, and distrust of medical care. Those interviewees who had high self-determination in medical care and self treatment attitudes showed strong distrust of medical care. 2) There were two groups with trend toward low compliance to the advice of a physician for a physician diagnosed illness: the group that had strong self-determination in medical care, and the group that had high distrust of medical care. The interviewees who had a strong tendency to see a physician for potentially serious illness had high self treatment attitudes, but disease prevention behaviors was not associated with all of four types. 3) In both communities, those interviewees who were younger and with higher educational levels showed strong distrust of medical care and had more self-determination attitudes. Those interviewees who had actually experienced problems in medical treatment showed less dependence on medical care and more distrust of medical care compared to those who had not. In Yokohama, distrust of medical care appeared to be higher among those interviewees who did not have a family doctor than those who had. 4) Distrust of medical care and self-determination in medical care was significantly higher in Yokohama than in Aikawa. The differences in the distribution of educational level and family doctors were a part of the reason for area differences in attitudes of distrust of medical care.     

Performance failure of an evidence-based upper respiratory infection clinical guideline.

BACKGROUND: We evaluated an upper respiratory infection (URI) clinical guideline to determine if it would favorably affect the quality and cost of care in a health maintenance organization. METHODS: Patients with URI symptoms contacting 4 primary care practices before and after guideline implementation were compared to ascertain what proportion of all patients with respiratory symptoms were eligible for treatment in accordance with the URI guideline; what proportion of eligible patients were managed without an office visit; and what proportion of eligible patients were treated with antibiotics, before and after guideline implementation. RESULTS: A total of 3163 patients with respiratory symptoms were identified. Of these, 59% (n = 1880) had disqualifying symptoms or comorbid conditions for URI guideline care, and 28% (n = 1290) received disqualifying diagnoses on the day of first contact, leaving 13% (n = 408) who received a diagnosis of URI and were eligible for care in accordance with the guideline. Among this group of patients, the proportion who received guideline-recommended initial telephone care was 45% preguideline and 47% postguideline (chi2 = 0.40; P = .82). Likelihood of a subsequent office visit increased from pre- to postguideline (chi2 = 17.1; P <.01), although the majority of patients had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi2 = 3.97; P = .046), but antibiotic use during 21-day follow-up did not change (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguideline and $36.20 postguideline (P >.05). CONCLUSIONS: Only 13% of primary care patients with respiratory symptoms were eligible for URI guideline care. Among eligible patients, use of the guideline failed to decrease clinic visits, decrease antibiotic use during a 21-day period, or reduce cost of care to the health plan.     

Linkage with primary medical care in a prospective cohort of adults with addictions in inpatient detoxification: room for improvement

OBJECTIVE: To identify patient characteristics and health care experiences associated with primary care linkage after alcohol or drug detoxification. DATA SOURCES/STUDY SETTING: Primary data collected over two years. Subjects were adults without primary medical care, in an urban residential detoxification program. STUDY DESIGN: A prospective cohort study in the context of a randomized trial of a linkage intervention, and an expansion of Medicaid benefits. DATA COLLECTION/EXTRACTION METHODS: Data were collected by interview assessment of predisposing, enabling, and illness variables. Linkage was defined as self-report of at least one visit with a primary care clinician during follow-up. PRINCIPAL FINDINGS: Of 400 subjects, 63 percent linked with primary medical care. In a multivariable model adjusting for randomization assignment, predisposing, enabling, and illness variables, women, those with no recent incarceration, those with support for abstinence by family or friends, and those who had visited a medical clinic or physician recently were significantly more likely to link with primary care. Those with health insurance during follow-up were also more likely to link. Recent mental health or addictions treatment utilization and health status were not associated with linkage. CONCLUSIONS: A substantial proportion of adults with addictions do not link with primary medical care. These data suggest that efforts could be focused on those least likely to link, that contacts with mental health and addictions treatment providers are underutilized opportunities for these efforts, and that health policy changes such as expanding health insurance benefits may improve entry of substance-dependent patients into primary medical care.     

Acute respiratory illness in the first year of primary school related to previous attendance at child care

Abstract: The aim of this study was to assess the relationship between previous child care outside the home (day care or family care) and acute respiratory illness in the first year at primary school. Participants were 445 Adelaide school children (mean age 5 years 2 months), 73 per cent of those eligible. Information about early childhood, family, child care arrangements and illness history was obtained from a questionnaire completed by parents. A respiratory illness score was calculated from the parental reports of respiratory illness experience in the winter months of the second school term in 1992. Absences from school owing to respiratory illness were counted from school records. Children who had attended child care before commencing school had fewer episodes of acute respiratory illness and had fewer absences from school than children with no child care experience. Children who had attended child care prior to commencing school experienced half as many episodes of asthma as those children who had never attended child care. Children who attend day care before age five tend to experience less acute respiratory illness than their peers on school entry. Possible explanations include selection of illness-prone children into home care, protection against respiratory illness as a result of early exposure, and a shift in the age-related peak of illness.     

‘Do I don’t I call the doctor’: a qualitative study of parental perceptions of calling the GP out‐of‐hours

The purpose of this study was to investigate how parents use the GP out‐of‐hours service. There was a lack of information about how parents managed childhood illness and what strategies they put in place to help them to cope before calling the GP. The investigation of parental perceptions was based on a qualitative design using in‐depth interviews of 29 families from a semi‐rural location in the south‐east of England. All parents said they found dealing with a sick child out‐of‐hours stressful and were concerned to make the right decision for their child. Furthermore, parents usually employed a reasonable strategy in attempting to manage the child’s illness. This study demonstrated that the decision to call the doctor was not taken lightly. Many parents had implemented useful strategies prior to calling the doctor. However, most parents were also aware of their limitations and feared doing the wrong thing. It would seem that on occasion this fear combined with factors such as a lack of social support and loss of parental confidence resulted in calling the doctor out of hours to seek ‘peace of mind’. A rethink is needed among health professionals about the ‘problem’ of out‐of‐hours calls. GPs could actively seek to empower parents by educating them about minor illness during visits and consultations. It is not enough to offer reassurance to parents that their children are fine. Health visitors and other health professionals who come into contact with young families may help to educate and empower.     

Improving Care of Upper Respiratory Infections Among Latino Early Head Start Parents

Misconceptions about upper respiratory infections (URI) and their treatment are widely held, especially among Latino parents, and are associated with increased health care visits. The Centers for Disease Control and Prevention recommends community based interventions to educate families about URI. We designed a community-based, culturally competent health literacy intervention regarding URI, which was pilot tested with Latino Early Head Start (EHS) parents. In depth interviews were conducted to understand parents’ perceptions. A paired-sample Wilcoxon signed rank test was used to assess change in pre-post knowledge/attitudes scores. Changes in care practices are described. Parents were very positive about this education, were open to non-antibiotic URI care, and reported that materials were helpful. Following the intervention, the mean composite knowledge/attitude score increased from 4.1 (total: 10) to 6.6 (P < .05). Families also reported improved care practices. EHS sites are promising locations for health literacy interventions regarding URI.     

The content of adult primary care episodes.

In a research project undertaken to describe the content of adult primary care, episodes of illness for six common primary care conditions were analyzed: URI (upper respiratory infection, UTI (urinary tract infection), HYP (hypertension), AP (abdominal pain), CP (chest pain), and PE (physical examination). Data from the Kaiser-Permanente Medical Care Program-Oregon Region were used in the project. Episode of the six conditions studied tended to be of brief duration; at least half of the episodes of each condition except hypertension involved only a single medical visit. The physical examination episodes typically involved both laboratory and radiology services, but these services were less frequently used for the other five conditions. Few episodes involved a referral to a consultant physician, the use of sophisticated ancillary procedures, repeat tests, or a hospitalization. If patients had been billed for the episode-related care involved in treating each episode, the average charge incurred (in 1980 dollars) would have bee: URI $38.67, UTI and HY $52.27 each, AP $66.59, CP $46.54, and PE $91.65, excluding the costs of pharmaceuticals. Ancillary services accounted for one-third or more of the costs for each type of episode except URI. The results suggest that cost savings in primary care are likely to depend less on the control of sophisticated medical technology than on efficiently meeting patient-initiated demands for care and on influencing physician-generated ordering of simple ancillary procedures. The results also suggest the utility of analyzing the distinctive demands on the medical care system that are generated by diverse primary care conditions.     

Passive smoking and its impact on employers and employees in Hong Kong

Aims: To estimate the prevalence of passive smoking at work in the whole workforce in Hong Kong (population 6.8 million), the characteristics of the passive smokers, any extra use of health care among passive smokers, and who pays for that health care.

Methods: A random sample of 14 325 households was contacted by telephone; 6186 responding adults who worked full time were asked about their employment, their most recent use of health care and the cost of that care, their medical benefits, and their exposure to secondhand smoke in the workplace. After weighting the sample for sex, age, household size, and income, 4739 subjects were included in the analysis.

Results: Of 1961 full time workers who did not smoke, 47.5% were exposed to secondhand smoke in the workplace compared with only 26% exposed at home. Exposure at work was associated with being younger, male, married, less educated, and having a lower income. Those exposed at work were 37% more likely to report having visited a doctor for a respiratory illness in the previous 14 days. Employers were paying 28% of the cost of these visits, the government paid 8%, and the individuals paid 63%. If extrapolated to the 3 million workers in the Hong Kong population, employers would pay just over US$9 million per year, while the affected workers would pay around US$20 million.

Conclusion: As well as the costs of active smoking, the cost of extra health care utilisation associated with passive smoking is an additional cost being paid by those employers who have not established smoke free workplaces and by their employees.