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Acute care utilization due to hospitalizations for pediatric lower respiratory tract infections in British… Santibanez, Pablo; Gooch, Katherine; Vo, Pamela; Lorimer, Michelle; Sandino, Yurik Dec 8, 2012

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RESEARCH ARTICLE Open AccessAcute care utilization due to hospitalizations forpediatric lower respiratory tract infections inBritish Columbia, CanadaPablo Santibanez1, Katherine Gooch2*, Pamela Vo2, Michelle Lorimer3 and Yurik Sandino4AbstractBackground: Pediatric LRTI hospitalizations are a significant burden on patients, families, and healthcare systems.This study determined the burden of pediatric LRTIs on hospital settings in British Columbia and the benefits ofprevention strategies as they relate to healthcare resource demand.Methods: LRTI inpatient episodes for patients <19 years of age during 2008–2010 were extracted from the BCDischarge Abstract Database. The annual number of acute care beds required to treat pediatric LRTIs was estimated.Sub-analyses determined the burden due to infants <1 year of age and high-risk infants. Population projectionswere used to forecast LRTI hospitalizations and the effectiveness of public health initiatives to reduce the incidenceof LRTIs to 2020 and 2030.Results: During 2008–2010, LRTI as the primary diagnosis accounted for 32.0 and 75.9% hospitalizations for diseasesof the respiratory system in children <19 years of age and infants <1 year of age, respectively. Infants <1 year ofage accounted for 47 and 77% hospitalizations due to pediatric LRTIs and pediatric LRTI hospitalizations specificallydue to respiratory syncytial virus (RSV), respectively. The average length of stay was 3.1 days for otherwise healthyinfants <1 year of age and 9.1 days for high-risk infants (P <0.0001). 73.1% pediatric LRTI hospitalizations occurredbetween November and April. Over the study timeframe, 19.6 acute care beds were required on average to care forpediatric LRTIs which increased to 64.0 beds at the peak of LRTI hospitalizations. Increases in LRTI bed-days of 5.5and 16.2% among <19 year olds by 2020 and 2030, respectively, were predicted. Implementation of appropriateprevention strategies could cause 307 and 338 less LRTI hospitalizations in <19 year olds in 2020 and 2030,respectively.Conclusion: Pediatric LRTI hospitalizations require significant use of acute care infrastructure particularly betweenNovember and April. Population projections show the burden may increase in the next 20 years, butimplementation of effective public health prevention strategies may contribute to reducing the acute care demandand to supporting efforts for overall pediatric healthcare sustainability.Keywords: Pediatrics, Lower respiratory tract infection, Acute care resource utilization, British Columbia* Correspondence: Katherine.gooch@abbott.com2Abbott Laboratories, 200 Abbott Park Road, Abbott Park, IL 60064, USAFull list of author information is available at the end of the article© 2012 Santibanez et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Santibanez et al. BMC Health Services Research 2012, 12:451http://www.biomedcentral.com/1472-6963/12/451BackgroundLower respiratory tract infections (LRTIs) in childrenand infants are common and can require hospitalization;thus, they are a major public health concern. A numberof viruses including respiratory syncytial virus (RSV), in-fluenza viruses, parainfluenza viruses, rhinovirus, andadenovirus are responsible for LRTIs. In children andinfants, RSV is the most common cause; during the firstyear of life 50%–70% of children will have an RSV infec-tion, and by the third year of age almost all children willhave been infected.1Neonatal and pediatric LRTIs and RSV are often mild,but can be associated with significant health resourceutilization and result in an important burden on thepatients, families, infrastructure, and budget of publichealthcare systems [1]. Economic analyses indicate thatsubstantial costs are associated with outpatient physicianoffice and emergency department visits, but that a ma-jority of the financial burden is accounted for by costs ininpatient hospital settings [2,3]. LRTI and RSV/LRTIhospitalization rates for all children <2 years of age varybetween 0.5% and 2% [4]. In comparison, LRTI, and par-ticularly RSV specific LRTI, hospitalization rates andlengths of stay in infants and high-risk infants are sub-stantially increased and associated with additional costs[3,4]. High-risk infants include early and late-preterminfants and those with bronchopulmonary dysplasia andcongenital heart disease [3,5].In Canada, the annual cost of RSV-associated illness isover $18 million, and inpatient services associated withRSV/LRTI hospitalizations account for 62% of these an-nual expenditures [2]. Over the past two decades, theimpact of LRTI hospitalizations on Canadian health re-source utilization has increased as the incidences ofadmissions have risen from approximately 6,200 to12,000 hospitalizations per year in children <2 years ofage [2,6,7]. In addition, there is a pronounced seasonalvariation in the incidence of LRTIs. This is likely due tothe RSV season which is defined by the timing of theonset and offset of increased RSV circulation in a com-munity. In northern hemisphere countries, the RSV sea-son usually runs from December through April and isassociated with significantly increased pediatric admis-sions for LRTIs [8].The burden of disease associated with LRTIs may bereduced by effective public health prevention strategiesthat decrease hospitalizations and reduce lengths of stay[4]. Indeed, epidemics such as the most recent H1N1outbreak led to rapid and important health preventionand public health initiatives to try to reduce the risk oftransmission and health morbidity [9,10]. Although theeffectiveness of such public health awareness campaignsare difficult to ascertain, any strategies that can decreasethe incidence of severe viral respiratory infections areexpected to have a considerable and important impacton acute care settings.To date there is limited information describing theburden of pediatric LRTIs and the impact of publichealth prevention strategies directed against the infec-tions causing LRTIs on hospital settings. In large coun-tries such as Canada, reducing the present and projectedburden of LRTIs and RSV on the public healthcare sys-tem involves detailed evaluations of the impact of thesediseases on acute care in defined regions. In Canada, itis likely that identification of the burden of a disease in aspecific province will enable the development of effectivepublic health initiatives to reduce the incidence of thedisease in this province. The experience in one provincemay serve as a model for provinces and territoriesthroughout the rest of the country. Accordingly, the goalof these analyses was to determine the burden ofpediatric LRTIs on hospital settings in British Columbiaand to identify the benefits of prevention strategies asthey relate to healthcare resource demand.MethodsThe objectives of the study were to describe the overallburden and inpatient resources required to care forpediatric LRTI hospitalizations in British Columbia fromApril 2008 to March 2010. The patient and hospital bur-den as it relates to the length of stay in hospital and thedifferences between pediatric sub populations includingthose <1 year of age and those defined as high-risk weredetermined. Population estimates in British Columbiafor 2008–2010 and projections to 2020 and 2030 wereused to model the projected demand for pediatric LRTIhospitalizations up to 2020 and 2030. In addition, quan-titative estimates of the effects of non-pharmacologicalinterventions to decrease the incidence of LRTIs weregenerated to assess how the impact of effective publichealth prevention strategies relate to decreased demandon hospital settings in this province.The pediatric population was defined as childrenyounger than 19 years of age at the time of hospitaladmission [11,12]. Pediatric population estimates for2008–2010 and growth statistics were obtained fromBC STATS [13]. BC STATS is the official source for popu-lation figures within British Columbia health authorities.The analyses were based on the PEOPLE 35 [13] releasewhich contains population counts by year, gender, localhealth area, and individual year of age. Data projectingpediatric population growth for 2020 and 2030 wereobtained from the BC STATS component/cohort-survival model [13].Hospital discharge records with an InternationalClassification of Diseases, Tenth Revision (ICD-10) codeidentifiable as LRTI as primary diagnosis during the2008–2009 (n=2498) and 2009–2010 (n=2090) fiscalSantibanez et al. BMC Health Services Research 2012, 12:451 Page 2 of 10http://www.biomedcentral.com/1472-6963/12/451years (April 1st to March 31st) for inpatient separationsassociated to pediatric patients from any acute care hos-pital in British Columbia were obtained from the CanadianInstitute for Health Information (CIHI) Discharge Ab-stract Database (DAD) [14]. Codes to identify an ad-mission due to an LRTI are shown in Table 1 [15].The DAD contains data on facility discharges acrossCanada including demographic, administrative, andclinical data for hospital discharges (inpatient acute,chronic, and rehabilitation) and day surgery interven-tions. Co-morbidities and other conditions were derivedfrom ICD-10 diagnosis codes specified in any of thefirst 10 diagnosis fields in the DAD published population.Data for this project was provided by the Fraser HealthAuthority (FHA). Access to the data was approved byFHA’s research office. An ethics approval exemption wasgranted on the basis of the study using unidentifiable non-clinical/administrative data at an aggregate level for pur-poses of reviewing workload and resource utilization andplanning capacity into the future.Data were examined by patients’ age, sex, hospital ofadmission, local health areas of residence, and admissiondate. Hospital length of stay (LOS) and accompanyingdiagnoses listed with the LRTI hospitalization weredescribed. LOS was obtained directly from the DAD’scalculated LOS field, which is a derived variable. Forinpatient abstracts, LOS is the difference in days betweenthe admission date and discharge date. If the differencewas 0 (i.e., admission date equals discharge date), thecalculated LOS was 1. LOS was described for all pediatricpatients, infants <1 year of age at the time of hospital ad-mission, as well as for infants at high risk for an LRTIhospitalization. High-risk infants were defined accordingto the ICD-10 codes for congenital heart disease, broncho-pulmonary dysplasia, congenital lung disease, and pretermbirth defined as <37 weeks completed gestation [5,15,16](Table 2).Average annual hospitalization rates for LRTI amongthe pediatric population were calculated. The overallhospitalization rates (per 100,000 children) were deter-mined using the total number of LRTI hospitalizationsand BC STATS PEOPLE 35 population estimates. Resultsare described as the number of hospital bed days used,Table 1 International Classification of Diseases, TenthRevision (ICD-10) codes identifying for lower respiratorytract infectionsICD-10CodeDescriptionJ10.1 Influenza due to other influenza virus withJ10.81 Influenza gastroenteritisJ10.89 Influenza due to other influenza virus withJ12.0 Adenoviral pneumoniaJ12.1 Respiratory syncytial virus pneumoniaJ12.2 Parainfluenza virus pneumoniaJ12.3 Pneumonia due to SARS-associated coronavirusJ12.8 Other viral pneumoniaJ12.81 Pneumonia due to SARS-associated coronavirusJ12.89 Other viral pneumoniaJ12.9 Viral pneumonia, unspecifiedJ13.0 Pneumonia due to Streptococcus pneumoniaeJ14.0 Pneumonia due to Hemophilus influenzaeJ15.0 Pneumonia due to Klebsiella pneumoniaeJ15.1 Pneumonia due to PseudomonasJ15.20 Pneumonia due to staphylococcus, unspecifiedJ15.21 Pneumonia due to Staphylococcus aureusJ15.29 Pneumonia due to other staphylococcusJ15.3 Pneumonia due to streptococcus, group BJ15.4 Pneumonia due to other streptococciJ15.5 Pneumonia due to Escherichia coliJ15.6 Pneumonia due to other aerobic Gram-negative bacteriaJ15.7 Pneumonia due to Mycoplasma pneumoniaeJ15.8 Pneumonia due to other specified bacteriaJ15.9 Unspecified bacterial pneumoniaJ16.0 Chlamydial pneumoniaJ16.8 Pneumonia due to other specified infectious organismsJ17.0 Pneumonia in diseases classified elsewhereJ18.0 Bronchopneumonia, unspecified organismJ18.1 Lobar pneumonia, unspecified organismJ18.2 Hypostatic pneumonia, unspecified organismJ18.8 Other pneumonia, unspecified organismJ20.0 Acute bronchitis due to Mycoplasma pneumoniaeJ20.1 Acute bronchitis due to Hemophilus influenzaeJ20.2 Acute bronchitis due to streptococcusJ20.3 Acute bronchitis due to coxsackie virusJ20.4 Acute bronchitis due to parainfluenza virusJ20.5 Acute bronchitis due to respiratory syncytial virusJ20.6 Acute bronchitis due to rhinovirusJ20.7 Acute bronchitis due to echovirusJ20.8 Acute bronchitis due to other specified organismsJ20.9 Acute bronchitis, unspecifiedTable 1 International Classification of Diseases, TenthRevision (ICD-10) codes identifying for lower respiratorytract infections (Continued)J18.9 Pneumonia, unspecified organismJ21.0 Acute bronchiolitis due to respiratory syncytial virusJ21.1 Acute bronchiolitis due to human metapneumovirusJ21.8 Acute bronchiolitis due to other specified organismsJ21.9 Acute bronchiolitis, unspecifiedJ22.0 Unspecified acute lower respiratory infectionSantibanez et al. BMC Health Services Research 2012, 12:451 Page 3 of 10http://www.biomedcentral.com/1472-6963/12/451and assuming a 100% utilization rate, results show theaverage number of beds required full time to care forLRTI patients during the study period of 2008 to 2010.The projected increases in acute care beds and beddays for LRTI hospitalizations in 2020 and 2030 were cal-culated based on rates for 2008–2010 and populationgrowth statistics provided by BC STATS. The best possibleestimates of the effectiveness of public health initiativesto reduce the incidence of LRTI in 2020 and 2030 wereestimated from a targeted literature review which ana-lyzed the effects of non-pharmacological interventionson hospitalizations for severe viral respiratory disease.Based on this review, the most reasonable and appropriatebenefit described as a decrease in the incidence of severeLRTI disease was applied to show the impact it wouldhave on hospital days and beds needed in 2020 and 2030.Statistical analysisAll statistical analyses were performed with the use ofMedCalc software, version 12.1.1 [17]. A MS Access2007 database containing all inpatient records was usedto store, manipulate, filter, and summarize the data. MSExcel 2007 was used for basic computations and to pre-pare charts.Hospitalizations accounted for the total bed-days; theaverage number of beds was defined as total bed-daysdivided by the number of days in the period under ana-lysis; average LOS was estimated as total bed-days dividedby the number of hospitalizations; and the peak in bedoccupancy was defined as the maximum number of bedsoccupied simultaneously.Rates were calculated using the best population esti-mates available and the number of hospitalizations forcorresponding groups defined by the patients’ primarydiagnosis, age, and region of residence. The confidenceintervals for these rates were calculated using the normalapproximation method. Chi-square tests were used forrate comparisons, with Yates’ correction for continuity.ResultsAll children (<19 years of age)In British Columbia during 2008–2010, diseases of therespiratory system (ICD-10 Chapter X) accounted for14326/186609 (7.7%) primary hospital diagnoses amongall children <19 years of age. Hospitalizations for LRTIas the primary diagnosis occurred in 4588/14326 (32.0%)of all respiratory admissions in children <19 years of age.The average LOS in hospital for LRTI as the primarydiagnosis was 3.10 days (95% confidence interval [CI]3.03–3.21; 82% within 5 days); this is equivalent to a yearlyaverage of 19.6 acute beds required to treat pediatricLRTIs (Table 3).Most of the LRTI admissions were for an unspecifiedviral cause (2932/4588; 63.9%). Pneumonia, organismTable 2 International Classification of Diseases, TenthRevision (ICD-10) codes identifying high-risk conditionsCondition ICD-10CodeDescriptionPre-term P07.2 Extreme immaturity of newbornP07.3 Other preterm newbornCHD Q20 Congenital malformations of cardiac chambersand connections (select subcategories)Q20.0 Common arterial trunkQ20.1 Double outlet right ventricleQ20.2 Double outlet left ventricleQ20.3 Discordant ventriculoarterial connectionQ20.4 Double inlet ventricleQ20.5 Discordant atrioventricular connectionQ20.6 Isomerism of atrial appendagesQ21 Congenital malformations of cardiac septa(select subcategories)Q21.0 Ventricular septal defectQ21.1 Atrial septal defectQ21.2 Atrioventricular septal defectQ21.3 Tetralogy of FallotQ21.4 Aortopulmonary septal defectQ21.8 Other congenital malformations of cardiac septaQ22 Congenital malformations of pulmonaryand tricuspid valves (all subcategories)Q23 Congenital malformations of aortic and mitralvalves (all subcategories)Q24 Other congenital malformations of heart(all subcategories)Q25 Congenital malformations of great arteries(select subcategories)Q25.0 Patent ductus arteriosusQ25.1 Coarctation of aortaQ25.2 Atresia of aortaQ25.3 Stenosis of aortaQ25.4 Other congenital malformations of aortaQ25.5 Atresia of pulmonary arteryQ25.6 Stenosis of pulmonary arteryQ25.7 Other congenital malformations of pulmonaryarteryQ26 Congenital malformations of great veins(all subcategories)BPD P27.1 Bronchopulmonary dysplasia originating inthe perinatal periodCLD Q33 Congenital malformations of lung(all subcategories)Santibanez et al. BMC Health Services Research 2012, 12:451 Page 4 of 10http://www.biomedcentral.com/1472-6963/12/451unspecified (ICD-10 code J18.9) was the most frequentlylisted LRTI as the primary diagnosis (1215/4588; 26.5%)with acute bronchiolitis due to RSV (ICD-10 code J21.0;1198/4588; 26.1 %); acute bronchiolitis, unspecified(ICD-10 code J21.9; 854/4588; 18.6%); bronchopneumo-nia, unspecified organism (ICD-10 code J18.0; 354/4588;7.7%); and viral pneumonia unspecified (ICD-10 codeJ12.9; 138/4588; 3%) also among the top 5 diagnoses.RSV-specific infections accounted for 1353 (29.5%)cases of LRTI as the primary diagnosis among all chil-dren <19 years of age. Most RSV-associated hospitaliza-tions were for acute bronchiolitis due to RSV accountingfor 1198 (86%) RSV-associated hospitalizations, followedby RSV pneumonia (ICD-10 code J12.1; 115 cases; 8.5%),and acute bronchitis due to RSV (ICD-10 code J20.5;40 cases; 3%).Infants (<1 year of age)During 2008–2010, diseases of the respiratory systemaccounted for 2853/102972 (2.8%) primary diagnosesamong infants <1 year of age (including deliveries/births).Hospitalizations for LRTI as the primary diagnosis oc-curred in 2165 (75.9%) infants <1 year of age. The aver-age LOS for LRTI as the primary diagnosis was 3.23 days(95% CI 3.10–3.37; 79.5% within 5 days); this translatesto a yearly average of 9.6 beds per day needed to treatLRTIs in infants <1 year of age (Table 3).RSV-specific infections accounted for 1042 (48.1%)cases of LRTI as the primary diagnosis among infants<1 year of age. Most RSV-associated hospitalizationswere for acute bronchiolitis due to RSV accounting for961 (92.2%) RSV-associated hospitalizations, followed byRSV pneumonia (52 cases; 5%), and acute bronchitis dueto RSV (29 cases; 2.8%).Acute bronchiolitis due to RSV was the most frequentlylisted LRTI as the primary diagnosis (961/2165; 44.4%)followed by acute bronchiolitis, unspecified (575/2165;26.6 %); pneumonia, unspecified organism (194/2165;9%); bronchopneumonia, unspecified organism (102/2165;4.7%); and acute bronchiolitis due to other specifiedorganisms (ICD-10 code J21.8; 51/2165; 2.4%).Infants <1 year of age accounted for 47 and 77% ofLRTI and RSV-specific LRTI hospitalizations, respect-ively, among all children (Figure 1). Hospitalization ratesfor LRTI as the primary diagnosis among infants <1 yearof age were significantly increased compared to children1–<19 years of age (2410/100,000 population <1 year ofage vs. 235/100,000 children 1–<19 years of age;P <0.0001). Bed-days rates for LRTI as the primary diag-nosis were significantly increased among infants <1 yearof age compared to children 1–<19 years of age (15,663/100,000 population <1year of age vs. 1473/100,000children 1–<19 years of age; P <0.0001). Consideringthe bed days spent by those patients, this is an equivalentbed rate of 21.45 beds/100,000 infants <1 year of ageper day and 2.02 beds/100,000 children 1–<19 years ofage per day (P <0.0001).Infants at riskAt-risk infants accounted for 1.8% (40/2165) of LRTIhospitalizations in all infants <1 year of age. The averageLOS among at-risk infants was significantly longer com-pared to other pediatric patients (9.1 days, vs. 3.10 days,respectively P <0.0001) (Table 4).Seasonal and regional variationsMost LRTI hospitalizations among all children <19 yearsof age (LRTI, 73.1%; RSV, 88.1%) and infants <1 yearof age (LRTI, 79.1%; RSV, 88.4%) occurred betweenNovember and April (Figure 2). Bed occupancy washighest in January and February of 2009 and March of2010 with peaks of 53 beds among all children <19 yearsof age and 40 beds among infants <1 year of age in Januaryand February 2009, respectively, and 64 beds among allchildren <19 years of age and 41 beds among infants<1 year of age in March 2010. Regionally, LRTI hos-pitalization rates among all children <19 years of ageand infants <1 year of age in the Interior, NorthernBC, and Vancouver Island were higher than the averageprovincial rate and significantly lower in British Columbia’slower mainland (Table 5).Projected LRTI hospitalizations for 2020 and 2030Population projections estimated a 6.6% growth in thepediatric population by 2020 and 17.2% growth by 2030(Table 6). Assuming the same incidence of LRTI hospita-lizations required by pediatric patients, these projectionspredicted a growth in LRTI bed-days of 5.5% amongall children <19 years of age and 16.3% among infants<1 year of age by 2020 and 16.2% among all children<19 years of age and 14.9% among infants <1 year ofage by 2030. In 2020, the average number of acute carebeds required to treat pediatric LRTIs will be 20.7 amongall children 0–<19 years of age including 11.2 among thesubpopulation of infants <1 year of age. This will increaseto a maximum bed occupancy of 68 among all childrenincluding 48 in infants <1 year of age during the peakmonths for LRTI hospitalizations. In 2030, 22.8 acuteTable 3 Pediatric hospitalizations for lower respiratorytract infection as primary diagnosis, 2008–2010Cases Days ALOS (95% CI) AvBedsMax.BedsAll children 4588 14319 3.10 (3.03–3.21) 19.6 64Infants <1y 2165 7002 3.23 (3.10–3.37) 9.6 41Bed days are for separations within both fiscal years (length of stay of casesdischarged).Average beds calculated at 100% utilization (equivalent to average across year).Maximum beds correspond to peak in daily bed utilization.Santibanez et al. BMC Health Services Research 2012, 12:451 Page 5 of 10http://www.biomedcentral.com/1472-6963/12/451care beds will be needed among all children <19 years ofage including 11.0 among infants <1 year of age. This willincrease to a maximum bed occupancy of 74 beds amongall children including 47 among infants <1 year of age inthe winter months (Table 7).Impact of public health prevention strategies on futureLRTI hospitalizationsA targeted literature review quantitating the effect ofnon-pharmacological interventions on LRTI hospitaliza-tions revealed a study that indicated a 12.5% reductionin hospitalizations may be achieved using hand-washingas a public health prevention strategy [18]. This reduc-tion was applied to the projected increase in LRTITable 4 Hospitalizations and average length of stayamong high-risk compared to otherwise healthy patients,2008–2010Infants <1 y Children 1–<19 TotalRisk level Count ALOS (95% CI) Count ALOS (95% CI) CountHigh risk 40 9.10 (5.5–12.7) 38 4.3 (0–15.1) 78Healthy 2125 3.10 (3.0–3.2) 2385 3.0 (2.9–3.1) 4510ALOS, Average Length of Stay.The average length of stay (ALOS) among at-risk infants was significantlylonger compared to other pediatric patients (9.1 days, vs. 3.10 days,respectively P <0.0001).Figure 1 Pediatric hospitalizations for LRTI and RSV according to age, 2008–1010. A. Pediatric lower respiratory tract infection (LRTI)hospitalizations. Infants <1 year of age accounted for 47 % of LRTI hospitalizations among all children B. Pediatric respiratory syncytial virus (RSV)specific hospitalizations. Infants <1 year of age accounted for 77% RSV-specific LRTI hospitalizations among all children.Santibanez et al. BMC Health Services Research 2012, 12:451 Page 6 of 10http://www.biomedcentral.com/1472-6963/12/451hospitalizations for 2020 and 2030 and indicated that aprevention strategy that could replicate these findings inreducing the prevalence of LRTI admissions, in a sense,counteracts the effects of population growth. In 2020, a12.5% decrease in hospitalizations in an anticipated <19year old British Columbia pediatric population of 1,025,000could potentially result in 307 less hospitalizations, 963 lessFigure 2 Pediatric hospitalizations for LRTI and RSV according to month and year of discharge, 2008–2010. A. Lower respiratory tractinfection (LRTI) hospitalizations in all children. 73.1% LRTI hospitalizations among all children <19 years of age and 79.1% LRTI hospitalizationsamong infants <1 year of age occurred between November and April. B. Respiratory syncytial virus (RSV) specific hospitalizations in all children.88.1% RSV hospitalizations among all children <19 years of age and 88.4% RSV hospitalizations among infants <1 year of age occurred betweenNovember and April.Table 5 Hospitalization rates for lower respiratory tractinfection as primary diagnosis by region, 2008–10Health Authority Infants All children <19Interior 3049 (2634;3464) * 289 (263;316) *Fraser 2030 (1821;2239) * 203 (188;217) *Vancouver Coastal 1790 (1532;2047) * 174 (156;191) *Vancouver Island 3085 (2661;3509) * 272 (246;299) *Northern 3626 (3019;4234) * 373 (330;416) *British Columbia 2410 (2309;2511) 235 (228;241)Rates are per 100,000 population; 95% CI are shown in parentheses.Rates for All Children include infants and patients up to 19 years of age.(*) indicates significant difference (P value < 0.0001) in rates for healthauthority vs. provincial average.Lower respiratory tract infection hospitalization rates among all children <19years of age and infants <1 year of age in the Interior, Northern BC, andVancouver Island were higher than the average provincial rate andsignificantly lower in British Columbia’s lower mainland.Table 6 British Columbia population estimates andprojections to 2020 and 2030. Population projectionsestimated a 6.6% growth in the pediatric population by2020 and 17.2% growth by 2030Age Group 2008 2020 2030Infants <1 44,156 52,032 51,410All children <19 912,762 973,395 1,069,974Source: BC Stats PEOPLE 35.Santibanez et al. BMC Health Services Research 2012, 12:451 Page 7 of 10http://www.biomedcentral.com/1472-6963/12/451bed-days, and 2.6 less beds required annually to treatLRTIs. A 12.5% decrease in hospitalizations in an antici-pated <1 year old British Columbia pediatric population of52,032 could result in 160 less hospitalizations, 519 lessbed-days, and 1.5 less beds. Similarly in 2030, in a pro-jected <19 year old population of 1,128,585, there couldbe 338 less hospitalizations, 1060 less bed-days, and 2.9less beds required annually to treat LRTIs. In a pro-jected <1 year old population of 51,410, there could be158 less hospitalizations, 513 less bed-days, and 1.4 lessbeds (Table 7).DiscussionLRTIs and particularly RSV associated LRTIs accountfor a substantial number of pediatric hospitalizationsand utilize an important number of beds. In BritishColumbia during 2008–10, LRTI as the primary diagno-sis accounted for a significant proportion of diseases ofthe respiratory system in all children <19 years of ageand the majority of hospitalizations for diseases of therespiratory system in infants <1 year of age. Infants <1year of age accounted for 47 and 77% hospitalizations dueto pediatric LRTIs and LRTIs specifically due to RSV, re-spectively. Acute bronchiolitis due to RSV was the mostfrequently listed LRTI as the primary diagnosis in infants<1 year of age. There was considerable seasonal variationin the incidence of hospitalizations. Most pediatric hospi-talizations attributable to LRTIs in British Columbia hos-pitals occurred between November and April.These data demonstrate that LRTI and RSV specificLRTI are a significant disease burden in the pediatricpopulation in British Columbia, especially in infants<1 year of age and those at high-risk. Although high-riskinfants do not account for the majority of the number ofpediatric LRTI hospitalizations, their hospital LOS wasthree times as long as other pediatric patients. This sug-gests at-risk infants place a greater demand per patienton the acute care setting. Previous studies show thelengths of RSV-associated stay in Canada range from4.6 to 6.7 days for pediatric patients, and from 8.6 to11.8 days for pediatric patients with diagnoses such ascongenital heart disease, chronic lung disease, immuno-deficiency, or multiple congenital anomalies, [19] and upto 14.71 days for preterm infants with probable RSV com-pared to 5.04 days for term infants [20]. These data arein accordance with our observations in British Columbia.Due to the high rate of pediatric hospitalization andextended lengths of stay, there are significant medicalcosts related to LRTI. Previous economic analyses indi-cate that infants with LRTI have healthcare costs over$9000 higher in the first year of life than infants withoutinfection [21]. The LRTI burden on the healthcare sys-tem in British Columbia is expected to increase in thenext 20 years as estimates of population growth suggestthat the number of acute care beds needed to care forpediatric LRTI hospitalizations will rise. The study esti-mated an increase in the pediatric population of approxi-mately 17% by 2030 which may be a conservative estimatecompared to other published reports which calculate 31%growth in the population of children 0–19 years of agein British Columbia from 2010 to 2031 [22]. However,predictions describing the implementation and evaluationof effective public health prevention strategies indicatethat such measures can potentially reduce the incidenceof the severe viral infections that are predominant con-tributors to LRTI hospitalizations and can significantlycontribute to pediatric acute care sustainability. Non-pharmacological intervention strategies can occur in thehome, and health care practitioners need to educate par-ents and caregivers about methods that can be used toprevent children from infections. These include frequenthand washing which can significantly reduce the rate ofspread of infection from 4.2 to 0.6–1.1% [23] and sepa-rating infected people from non-infected people, espe-cially at-risk children [24]. The effectiveness of otherpublic health initiatives warrants evaluation.Table 7 Projections for lower respiratory tract infection hospitalizations with and without a public health interventionstrategyYear(s) Hospitalizations All Children Bed-days All Children Beds All ChildrenInfants Infants InfantsActual 2008-10 1,083 2,294 3,501 7,160 9.6 (41) 19.6 (64)Proj1 2020 1,254 2,409 4,071 7,553 11.2 (48) 20.7 (68)2030 1,239 2,652 4,022 8,316 11.0 (47) 22.8 (74)Proj2 2020 1,094 2,102 3,552 6,590 9.7 (41) 18.1 (59)2030 1,081 2,314 3,509 7,256 9.6 (41) 19.9 (65)Beds correspond to annual average calculated from bed-days; peak in beds shown in parenthesis.Proj1=projections based solely on population growth.Proj2=Proj1 adjusted for public health intervention strategy.Population projections predicted a growth in lower respiratory tract infection (LRTI) bed-days of 5.5% among all children <19 years of age and 16.3% amonginfants <1 year of age by 2020 and 16.2% among all children <19 years of age and 14.9% among infants <1 year of age by 2030. A public health preventionstrategy that reduces LRTI hospitalizations by 12.5% may counteract the effects of population growth.Santibanez et al. BMC Health Services Research 2012, 12:451 Page 8 of 10http://www.biomedcentral.com/1472-6963/12/451The significance of developing public health responsestrategies to infectious diseases was illustrated duringthe 2009 H1N1 influenza pandemic. Public opinion pollsdemonstrated that 59–67% Americans adopted handwashing and 35–38% avoided exposure to others withinfluenza-like symptoms [10]. While the effectiveness ofsuch awareness campaigns are difficult to ascertain, strat-egies that can decrease the prevalence of LRTIs may haveconsiderable impact on acute care settings especiallyduring seasonal LRTI and RSV outbreaks. Compliancewith vaccines that are efficacious at reducing the inci-dence of severe viral respiratory infections [25] or theuse of monoclonal antibodies to reduce the risk of RSVhospitalization in high-risk infants [26] may also have asignificant contribution to reducing the demand of LRTIson pediatric inpatient settings. In some areas, a modifiedcombination of prevention may be useful. This may beapplicable in British Columbia in the Interior, NorthernBC, and Vancouver Island where LRTI hospitalizationrates among all children <19 years of age and infants<1 year of age were higher than the average provincialrate. Furthermore, this study revealed that the primarydiagnosis for LRTIs were predominantly for an unspecifiedcause. Improved surveillance on the cause of pediatricLRTI hospitalizations may provide valuable insight forassessing current and future demand as well as for devel-oping targeted prevention strategies.Our study reflects the impact of LRTIs in a closedpopulation [14]. This may be an advantage over othernationwide administrative analyses that only evaluate asample of a population. There are however limitationsassociated with this study. First, the use of ICD-10 codeswith hospital discharge diagnoses to estimate LRTI hos-pitalizations may be unsatisfactory as discharge diagnosescan be miscoded. Second, as previously noted the sensi-tivity of the use of LRTI ICD-10 codes is uncertain asmost of the LRTI hospitalizations were for an unspecifiedviral cause. The study was unable to determine if eachhospitalization had a laboratory investigation to determinethe underlying cause. Third, it is difficult to evaluate theimpact of health prevention strategies in decreasing severerespiratory disease as the effectiveness of such measuresmay only be quantified using the best estimates availablein the literature. Fourth, the future predictions on de-mand were based on 2008–2010 data only, whereby theretrospective inclusion of more years would potentiallyimprove the accuracy of estimating the temporal trendand demand. Fifth, the study only assessed the inpatientutilization of pediatrics with a primary LRTI diagnosis,whereby those with secondary diagnoses, for examplethose acquiring nosocomial LRTI, were not included.Finally, while our findings suggest that LRTIs are a sig-nificant burden on the healthcare system in BritishColumbia and public health prevention strategies canseverely impact this, the generalizability of this data toother provinces in Canada and other countries isunknown.ConclusionIn summary, we present data for all pediatric LRTIand RSV/LRTI hospitalization occurrences in BritishColumbia during 2008–2010. We identified pediatricLRTIs, and specifically in infants <1 year of age andat-risk infants, as a significant burden on the acute caresetting in British Columbia, having pronounced seasonalvariability. Population projections suggest that this bur-den will increase in the next 20 years whereby the imple-mentation of effective public health prevention strategiesmay be an important strategy for pediatric healthcaresustainability, particularly as it relates to acute care ac-cess with fixed infrastructure. Information about the riskof hospitalization in the pediatric population along witha greater understanding of the factors involved in theseasonality patterns of LRTI hospitalizations and the eti-ology for the LRTI hospitalizations may contribute to thedevelopment of algorithms that can identify risk andallow the development of prevention strategies to beimplemented at specific times of the year. Comprehen-sive knowledge of the province-specific impact andcause of pediatric LRTIs can lead to the developmentof prevention strategies that if effectively implementedcan ease the burden of disease on patients, health careinfrastructure, and budgets, all of which are importantfor healthcare sustainability. The methodology andanalyses used to evaluate the burden of pediatric LRTIsin British Columbia may serve as a model that can beextrapolated for use in other Canadian provinces andcountries.AbbreviationsLRTI: Lower Respiratory Tract Infection; RSV: Respiratory Syncytial Virus.Competing interestsYS has no competing interests or conflicts of interest to disclose.Authors’ contributionsPS participated in the study design, identified the data requirements, carriedout the analysis and helped to draft the manuscript. KG conceived of thestudy, participated in its design and coordination, provided interpretation tothe results and drafted the manuscript. PV participated in the interpretationof results. ML participated in the design and coordination of the study anddrafting of manuscript. YS arranged the provision of data and contributed inthe interpretation of the analysis. All authors read and approved the finalmanuscript.Ethics statementNon-identifiable administrative data was utilized for the purposes of thisanalysis and therefore ethics approval was not required.AcknowledgementsThis study was funded by Abbott Laboratories. KG and PV are employees ofAbbott Laboratories and own Abbott stock, PS, and ML received aconsulting fee from Abbott Laboratories and have no other financial or non-financial competing interests to disclose.Santibanez et al. BMC Health Services Research 2012, 12:451 Page 9 of 10http://www.biomedcentral.com/1472-6963/12/451Author details1Sauder School of Business, University of British Columbia, 2053 Main Mall,Vancouver, BC V67 1Z2, Canada. 2Abbott Laboratories, 200 Abbott Park Road,Abbott Park, IL 60064, USA. 3Lorimer Enterprises, Inc., 104 Dixon Crescent RedDeer, Alberta T4R 2H5, Canada. 4Fraser Health Authority, Suite 400, CentralCity Tower 13450-102nd, Avenue Surrey, BC V37 0H1, Canada.Received: 30 December 2011 Accepted: 2 November 2012Published: 8 December 2012References1. Simoes EA, Carbonell-Estrany X: Impact of severe disease caused byrespiratory syncytial virus in children living in developed countries.Pediatr Infect Dis J 2003, 22:S13–S20.2. Langley JM, Wang EEL, Law BJ, Stephens D, Boucher FD, Dobson S,McDonald J, MacDonald NE, Mitchell I, Robinson JL: Economic evaluationof respiratory syncytial virus infection in Canadian children: a PediatricInvestigators Collaborative Network on Infections in Canada (PICNIC)study. J Pediatr 1997, 131:113–117.3. Shi N, Palmer L, Chu BC, Katkin JP, Hall CB, Masaquel AS, Mahadevia PJ:Association of RSV lower respiratory tract infection and subsequenthealthcare use and costs: a Medicaid claims analysis in early-preterm,late-preterm, and full-term infants. J Med Econ 2011, 14(3):335–340.4. Paes BA, Mitchell I, Banerji A, Lanctot KL, Langley JM: A decade ofrespiratory syncytial virus epidemiology and prophylaxis: Translatingevidence into everyday clinical practice. Can Respir J 2011, 18(2):e10–e19.5. Law BJ, Carbonell-Estrany X, Simoes EA: An update on respiratory syncytialvirus epidemiology: a developed country perspective. Respir Med 2002,96(SB):S1–S7.6. 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Goldman RD, Vohra S, Rogovik AL: Potential vitamin-drug interactions inchildren: at a pediatric emergency department. Paediatr Drugs 2009,11(4):251–257.13. BC Stats: Population extrapolation for organization planning with less error(p.e.o.p.l.e.), run cycle 35. Victoria, British Columbia: British Columbia Ministryof Management Services; 2010.14. Canadian Institute for Health Information: Discharge abstract database(DAD), acute care hospitalizations for the province of British Columbia. 2011.15. World Health Organization: International Statistical Classification of Diseaseand Related Health Problems, Tenth Revision (ICD-10). Geneva: World HealthOrganization; 2010.16. Simoes EA: Environmental and demographic risk factors for respiratorysyncytial virus lower respiratory tract disease. J Pediatr 2003, 143:S118–S126.17. MedCalc software, version 12.1. Mariakerke, Belgium. http://www.medcalc.org/.18. 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Statistics Canada: Population projections for Canada, provinces and territories2009–2036. Catalogue no. 91-520-X. Ottawa, Ontario: Statistics Canada; 2010.ISBN 0-0660-19525-9.23. Isaacs D, Dickson H, O’Callaghan C, Sheaves R, Winter A, Moxon ER: Handwashing and cohorting in prevention of hospital acquired infectionswith respiratory syncytial virus. Arch Dis Child 1991, 66:227–231.24. Austin J: Preventing respiratory syncytial virus in homebound prematureinfants. Home Healthc Nurse 2007, 25:429–432.25. Russell FM, Buttery J: Vaccine development for capsulate bacteria causingpneumonia. Curr Opinion Pul Med 2003, 9:227–232.26. The IMpact-RSV Study Group: Palivizumab, a humanized respiratorysyncytial virus monoclonal antibody, reduces hospitalization fromrespiratory syncytial virus infection in high-risk infants. Pediatrics 1998,102(3 Pt1):531–537.doi:10.1186/1472-6963-12-451Cite this article as: Santibanez et al.: Acute care utilization due tohospitalizations for pediatric lower respiratory tract infections in BritishColumbia, Canada. BMC Health Services Research 2012 12:451.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSantibanez et al. BMC Health Services Research 2012, 12:451 Page 10 of 10http://www.biomedcentral.com/1472-6963/12/451

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