Bronchiolitis bronchopneumonia and pneumonia Indicator Breast reduction

							                           Technical specification: Emergency admissions for children with lower respiratory infections




                                       NHS Performance Indicator 6 (ii),
                                            Clinical Indicator 7A

         Emergency admissions to hospital of children aged under 16 with
           lower respiratory infections, per 100,000 resident children




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                           Technical specification: Emergency admissions for children with lower respiratory infections




PART A: TECHNICAL SPECIFICATION

1.   Purpose:

     1.1. To help monitor NHS success in prevention and treatment outside hospital, for example, for the children’s
          indicators: smoking reduction, especially in young mothers; improved uptake and continuation of breast feeding;
          better support for young parents in the care of their children and in management of illnesses in the home by
          prevention, support such as Sure Start and easing access to health advice and therapy through NHS Direct and
          enhanced primary care. These form part of the NHS plan targets to reduce inequalities in childhood morbidity
          and mortality. There are similar interventions available to prevent some strokes and hip fractures.

2.   Rationale:

     2.1. Respiratory infections form one of the commonest reasons for hospital admission in childhood especially in
          infants. Between 1 and 3 % of all babies experience an admission with bronchiolitis and about 2.5 % of all child
          admissions are for pneumonia. Emergency admission rates in children, especially under age 5 years for lower
          respiratory infections - bronchiolitis, bronchopneumonia and pneumonia- reflect a variety of influences. Rates
          vary across the country but are increased in areas of socio-economic deprivation. They also vary between health
          authorities even when social deprivation is taken into account and then probably reflect variation in access to and
          expectation of health services and also clinical practice. There are linkages between higher breast feeding and
          reduction of exposure to tobacco smoke- preventive measures which reduce both incidence and severity of
          infections. Much childhood morbidity and a significant proportion of childhood mortality results from these
          lower respiratory infections. Thus its choice as a clinical indicator will enable trends for improvement to be
          monitored which should result from a variety of current policy interventions in health promotion, health care and
          parental support.


3.   Definition of indicator and its variants:

     3.1. The indirectly age and sex-standardised rate per 100,000 resident children of emergency admissions to hospital
          with lower respiratory infections.

     3.2. Data are presented for the financial years 1998-99, 1999-2000, 2000-01, standardised using 1998-99 data.

     3.3. Results are given by emergency method of admission and Health Authority of residence, for Health Authorities in
          England.

     3.4. Health Authority boundaries are as at April 2001.


4.   Numerator:

     4.1. Numerator data – The number of finished consultant admission episodes (epiorder 1) for ages 0-15, with an
          emergency method of admission and with any of the following primary diagnoses :

           Bronchiolitis, bronchopneumonia and pneumonia

           J10.0    Influenza with pneumonia virus identified
           J11.0    Influenza with pneumonia, virus not identified
           J11.1    Influenza with other respiratory manifestations, virus not identified (bronchiolitis with influenza)
           J12.-    Viral pneumonia nec
           J13      Pneumonia due to Streptococcus pneumoniae
           J14      Pneumonia due to Haemophilus influenzae
           J15.-    Bacterial pneumonia nec
           J16.-    Pneumonia due to other infectious organisms nec
           J18.0    Bronchopneumonia, unspecified
           J18.1    Lobar pneumonia
           J18.9    Pneumonia unspecified
           J21.-    Acute bronchiolitis.



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                           Technical specification: Emergency admissions for children with lower respiratory infections

     4.2. Source of numerator data – Hospital Episode Statistics for the financial year ending 31 March, England.

     4.3. Comments on numerator data –

           It is important, for the purposes of measuring incidence, to count persons as opposed to episodes of care, as each
           person with the condition should only be counted once. This is done by counting admission episodes (epiorder 1)
           only. Some transfers, which are also coded epiorder 1 and miscoded emergency could lead to double counting,
           however, the numbers are likely to be very small.

           Data are not linked across years, thus each year’s analysis relates to the episodes recorded for that HES year.

           Spells are counted to the Health Authority of residence, based on the numerator.

          There is variation in the completeness of hospital records and quality of coding (see Data Quality Indicators).
          These show the proportion of diagnoses not coded.

          There may be variation in the procedures for coding diagnoses to the various fields in each episode, particularly
          primary diagnosis. For instance, Trusts may code diagnoses chronologically or according to the degree of
          complexity. This may affect comparability of the data.

          The fields that are needed for the calculation of this indicator are shown at para 15 below.

5.   Denominator:

     5.1. Denominator data – Mid-year estimates of resident populations for the specified ages, based on 1991 census, of
          each Health Authority.

     5.2. Source of denominator data – Office for National Statistics.

     5.3. Comments on denominator data –
          The population figures used are ONS final mid-year population estimates for 1998, 1999 and 2000 derived from
          the 1991 census, with allowance for subsequent births, deaths, migration and ageing of the population.

6.   Statistical Methods:

     6.1. The section on ‘Explanation of Standardisation Methodology’ describes the methods used for indirect
          standardisation and estimation of confidence intervals.

7.   Interpretation of indicator:

     7.1. Type of indicator – This is a condition specific, cross-sectional annual comparative indicator, acting as a proxy
          for outcome. In the absence of an absolute standard, comparative data are useful for monitoring in relation to
          rates achieved in comparable institutions/areas.

     7.2. Quality of Indicator – The sensitivity, specificity, repeatability and responsiveness to change of the indicator has
          yet to be tested.

     7.3. Confidence Intervals – 95%. Some of the values and factors influencing them may be chance occurrences, with
          values fluctuating at random between organisations and from year to year. Numbers of admissions may be small
          at individual Health Authority level. The results should therefore be interpreted with caution and with the aid of
          confidence intervals. The 95% confidence interval provides a measure of the statistical precision of the rate for an
          area or institution. It indicates a range which, with 95% confidence, will contain the underlying value of the
          indicator. If the confidence interval for an area’s rate is outside the range of the national confidence intervals, the
          difference between the two rates is considered statistically significant. If the confidence intervals for two rates
          overlap, in most cases the difference between the rates would not be considered statistically significant.

     7.4. Effect of case-mix/severity – A number of factors outside the control of hospitals, such as the socio-economic mix
          of local populations and events prior to hospitalisation, may contribute to the variation shown by the indicators.
          Differences in case-mix, concurrent illnesses and other potential risk factors also contribute to the variation. The
          data available do not allow adjustment for any of these factors.




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                           Technical specification: Emergency admissions for children with lower respiratory infections

     7.5. Other potential confounding factors – The patterns of providing care may vary between Health Authorities in
          terms of: extent of treatment in primary care settings; referral policies and practices; hospital outpatient
          facilities/walk-in clinics; and hospital inpatient admission policies and practices for children.

8.   Potential value of indicator:

     8.1. To stimulate discussion and encourage local investigation, and to lead to improvement in data quality and quality
          of care.

9.   Potential for follow-up action leading to change:

     9.1. Examples of follow-up studies will be published in due course.


10. Relevant national initiatives:

     10.1. Reduction in hospital admission for lower respiratory infections is one of the selected SureStart targets, reduction
           of gradients in morbidity forms a major part of the targets for the NHS Plan. A new programme of health visiting
           and school nursing will be implemented including revisions of the universal child health surveillance programme
           anticipated in 2001. All these initiatives from part of the children 's taskforce and National Service Framework
           programme of work.


11. Further reading:

     Ashley, M. J., Ferrence, R. (1998). Reducing children's exposure to environmental Tobacco smoke in homes: issues and
          strategies. Tob Control 7: 61-65.

     Bauchner H., Leventhal J.M., Shapiro E.D. Studies of breastfeeding and infections. How good is the evidence?
          Journal of the American Medical Association. (1986).256,887-892.

     Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J
          Pediatr. 1995;126:191-197.

     Chen Y. Synergistic effect of passive smoking and artificial feeding on hospitalization for respiratory illness in early
          childhood. Chest. 1989;95:1004-1007.

     Department of Health / National Centre for Health Outcomes Development. Compendium of Clinical and Health
          Indicators 2000. London: National Centre for Health Outcomes Development, 2000.

     Dewey K.G., Heinig M.J., Nommsen-Rivers L.A. Differences in morbidity between breastfed and Formula fed infants.
         Journal of Paediatrics 1995; 126:696-702.

     Frank AL, Taber LH, Glezen WP, et al. Breast-feeding and respiratory virus infection. Pediatrics. 1982;70:239-245.

     Hawker J, Babatunde Olowokure, Sufi F, Weinberg J, O. Gill N, Wilson W. Social inequalities and hospital admission
         for respiratory infection. W Midlands PHLS : submitted 2000.

     Heinig M.J., Dewey K.G. Health advantages of breastfeeding for infants. Critical review. Nutrition Research Reviews
           1996; 9: 89-110.

     Howie P.W., Forsyth J.S., Ogston S.A., Clark A Florey C., Protective effect of breastfeeding against infection. British
          Medical Journal, 1990; 300: 11-16.

     MacFaul R, Jones S, and Werneke U Clinical training experience in district general hospitals Arch. Dis. Child. 2000
          83: 39-44.

     Spencer N, Logan S , Scholey S , Gentle S, Deprivation and bronchiolitis. Arch. Dis. Child. 1996 74: 50-52.

     Taylor, J., Spencer, N., Baldwin;, N., Sturge;, C., Speight, ANP, Hoghughi, M. Current topic: Social, economic, and
           political context of parenting. Arch. Dis. Child. 2000 , 82: 113-120.



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                           Technical specification: Emergency admissions for children with lower respiratory infections

   Wilson A., Forsyth S., Greene S., Irvine L., Hau C., Howie P. Relation of infant diet to childhood health: seven year
        follow up of cohort of children in Dundee infant feeding study. British Medical Journal. 1998; 316, 21-25.

   Wright AI, Holberg CJ, Martinez FD, et al. Breast feeding and lower respiratory tract illness in the first year of life.
        British Medical Journal. 1989;299:945-949.

   Wright AL, Holberg CJ, Taussig LM, et al. Relationship of infant feeding to recurrent wheezing at age 6 years. Arch
        Pediatr Adolesc Med. 1995;149:758-763




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                           Technical specification: Emergency admissions for children with lower respiratory infections

PART B: ALGORITHM USED TO PRODUCE INDICATOR CI 7

12. Fields needed for calculating indicator (see paras 18 and 19 for details)

     12.1           This indicator is based on the following information:

                    13.1.1. Fields from the admissionepisod:
                            SEX, ADMIMETH, STARTAGE, DIAG_1, RESHA,EPIORDER,EPISTAT

13. Numerator data:

     13.1 The Numerator is the number of admission episodes which have:
         a valid primary diagnosis; valid diagnoses are listed in 4.1

     13.2 Counts by:
           age / sex / admimeth / Health Authority

            where:
            age bands are <1, 1-4, 5-9, 10-15
            sex is 1, 2 (male and female),
            emergency admission = admimeth 21,22,23,24,28
            Counts are Health Authority of residence (values for England are aggregates of these).

14. Denominator data:

     14.1. Mid-year estimates of resident populations (aged 0-15 years), based on 1991 census, of each Health Authority.

     14.2. Counts by:
           age / sex / admimeth / Health Authority

            where:
            age bands are <1, 1-4, 5-9, 10-15
            sex is 1, 2 (male and female),
            Counts are Health Authority of residence (values for England are aggregates of these).




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                         Indicator 1 - Technical specification: Rates of deaths in hospital within 30 days of surgery


 15. HES fields used for deriving this indicator

HES field                Description of field                              Field used for                HES codes used for indicator

Epistat      Finished/unfinished consultant episode                     Indicator numerator          3
Sex          Sex                                                        Indicator numerator          1, 2
Epiorder     Episode order                                              Indicator numerator          01
Admimeth     Method of admission                                        Indicator numerator          Emer: 21,22,23,24,28

Startage     Age at the start of a finished consultant                  Indicator numerator          0-15
             episode
Diag_1       Primary diagnosis                                          Indicator numerator          Valid, eligible codes only (see para
                                                                                                     13.1)
Resha        Health Authority of residence                              Indicator numerator




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