Primary Service Area Research Articles

The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach.

Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies. We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and >60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and >60-day adjuvant delay. We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25). Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.

A GIS-Based Approach for Primary Substations Siting and Timing Based on Voronoi Diagram and Particle Swarm Optimization Method

The paper aims to provide primary substations’ optimal siting and timing to expand existing distribution networks. The proposed methodology relies on three main features: a geographic information system for capturing, elaborating, and displaying spatial input data; a particle swarm optimization algorithm to locate and timing the new primary substations; a Voronoi diagram-based approach to find the primary substation service areas and loading. The optimization criteria follow the approach of serving every customer from the nearest primary substation to ensure that the distribution delivery distance is as short as possible, reducing feeders’ cost, electric losses, and service interruption exposure. The algorithm also considers the primary substation transformers’ capacity limit. Thanks to Unareti, the distribution system operator of Milan and Brescia, the methodology was tested by carrying out several simulations, progressively increasing the number of new primary substations. The results obtained confirm the proposed approach’s effectiveness and show that the methodology is a valuable tool to guide Unareti, and distribution system operators in general, in expanding distribution networks to face the challenges of the energy transition.

Assessment of IRNSS-Only Data Processing: Availability, Single-Frequency SPP and Short-Baseline RTK

The Indian Regional Navigation Satellite System (IRNSS) currently can provide independent positioning services with eight in-orbit satellites. This study provides a comprehensive assessment of IRNSS-only data processing, including the availability of satellite constellation, the performance of single-frequency single point positioning (SPP), and the performance of single-frequency short-baseline real-time kinematic (RTK) positioning. Regarding the availability of IRNSS-only case in its primary service areas, the average number of visible satellites is 6–8, and the average Position Dilution of Precision (PDOP) value falls between 3.3 and 6.2, under a service rate of nearly 100.0%. The datasets from 14 stations located in the IRNSS service areas spanning a week are used for position determination. The results show that under the IRNSS single-system case, the positioning accuracy of the SPP is 6.031, 6.015, and 9.668 m in the east, north, and up directions, respectively, and the mean positioning bias of short-baseline RTK is 5.4, −21.1, and −0.2 mm with a standard deviation (STD) error of 7.8, 19.2, and 29.0 mm in the three directions, respectively. For comparative analysis, the results of the GPS single-system and GPS/IRNSS dual-system combination cases are also presented. The positioning performance of IRNSS is inferior to that of GPS, and the performance improvement of GPS/IRNSS dual-system integrated solutions over GPS single-system solutions is not significant. Furthermore, based on the GPS/IRNSS dual-system solutions, the inter-system bias estimates from SPP, the code observation residuals from SPP, and the carrier phase observation residuals from short-baseline RTK are characterized.

Hierarchy table of indicators and measures for the current status assessment of urban roads in smart cities

• A hierarchy table of indicators and measures for service areas is required for a smart city. • Keyword network analysis is used to develop a hierarchy table for urban roads in a smart city. • City officials can utilize the developed hierarchy table to understand the basic need for their road facilities to innovate towards a smart city. • The procedures presented to develop our hierarchy table can be utilized to develop other smart city service areas. Urban roads integrated with modern, innovative technologies (called advanced systems) serve as one of the primary service areas to support the function of a smart city. The extensive experience with the benefits that these advanced urban roads provide informs decision-makers toward efficient investments in advanced systems for urban roads. However, there is no tool designed to evaluate the developmental status of urban roads in a smart city. Therefore, this study has developed a hierarchy table of indicators and measures specific to assessing the current status of urban road innovation for smart cities. A keyword network analysis was used to develop the hierarchy table. The procedures take three phases: data preparation, data analysis, and hierarchy table development. As a result, the hierarchy table includes 53 measures in 14 indicators connected to the five smart city components (e.g., environment, mobility, governance, economy, and living). The hierarchy table can be used for city officials to assess the current status of urban roads in the transition of a smart city, which leads to an explicit investment decision on urban road innovation. The procedures presented in this study can be adapted to develop indicators and measures for other service areas necessary for a smart city.

Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA

This update to the 2013 joint position statement, Appropriate and Safe Utilization of Helicopter Emergency Medical Services, provides guidance for air medical services utilization based on currently available evidence. Air medical services utilization considerations fall into three major categories: clinical considerations, safety considerations, and system integration and quality assurance. Clinically, air medical services should accomplish one or more of three primary patient-centered goals: initiation or continuation of locally unavailable advanced or specialty care; expedited delivery to definitive care for time-sensitive interventions; and/or extraction from physically remote or otherwise inaccessible locations that limit timely access to necessary care. Ground-EMS (GEMS) transport is preferred when it is able to provide the necessary level of care and timely transport to definitive care. Risk identification and safety of both the patient and crew must be uniformly balanced against the anticipated degree of patient medical benefit. While auto-ready and auto-launch practices may increase access to air medical services, they also risk over-use, and so must be rigorously reviewed. Safety is enhanced during multi-agency emergency responses by coordinated interagency communication, ideally through centralized communication centers. Helicopter shopping and reverse helicopter shopping both create significant safety risks and their use is discouraged. Regional EMS systems must integrate air medical services to facilitate appropriate utilization in alignment with the primary patient goals while being cognizant of local indications, resources, and needs. To maximize consistent, informed air medical services utilization decisions, specific indications for and limitations to air medical services utilization that align with local and regional system and patient needs should be identified, and requests routed through centralized coordinating centers supported by EMS physicians. To limit risk and promote appropriate utilization of air medical services, GEMS clinicians should be encouraged to cancel an air medical services response if it is not aligned with at least one of the three primary patient-centered goals. Similarly, air medical services clinicians should be empowered to redirect patient transport to GEMS. Air medical services should not routinely be used solely to allow GEMS to remain in their primary service area.

Racial Disparities in Adult Cochlear Implantation.

To compare rates of cochlear implant referral and cochlear implantation across different races and to compare audiometric profiles of these patients. Retrospective study. Academic tertiary care institution. Demographic and audiometric data were collected for patients who underwent cochlear implant evaluation or cochlear implantation from 2010 to 2020. A total of 504 patients underwent cochlear implant evaluation; 388 met cochlear implant candidacy criteria, and 258 underwent implantation. Of the patients referred for cochlear implant evaluation, 68.5% were White, 18.5% were Black, and 12.3% were Asian, while the institution's primary service area is 46.9% White, 42.3% Black, and 7.7% Asian (P < .001). Black patients referred for cochlear implant evaluation had significantly worse hearing (mean pure-tone average [PTA] 84.5 dB, 26.1% word recognition) than White patients (mean PTA 78.2 dB, P = .005; 35.7% word recognition, P = .015) and Asians patients (mean PTA 77.9 dB, P = .04; 36.5% word recognition, P = .04). Black patients who underwent cochlear implant evaluation also had significantly worse AzBio scores than White patients: 24.5% versus 36.7% (P = .003). There was no significant difference in cochlear implantation rates between Black and White candidates (P = .06). Black patients undergo cochlear implant evaluation and cochlear implantation at rates disproportionately lower than expected based on local demographics. In addition, Black patients have significantly worse hearing at the time of cochlear implant referral than White and Asian patients. Identifying and increasing awareness of these disparities are essential steps to improving cochlear implant access for potentially disadvantaged populations.

Health Equity as a System Strategy: The Rush University Medical Center Framework

Summary Rush University Medical Center adopted a health equity strategy in 2016 in an effort to address the large life-expectancy gaps in its primary service area. The center named structural racism and economic deprivation as among the root causes for neighborhood-based racial health inequities and proposed an organizational anchor mission and equity strategy to begin to address the social and structural determinants of health that underpinned these racial health inequities. A dedicated senior executive team with experience and credibility and support from the board and the civic community are critical to the success of such an initiative. Listening sessions in the community and a commitment to share decision-making with community leaders are foundational to the strategy and necessary to overcome historical mistrust. Rush’s community efforts are guided by the voice of the community: “Nothing about us without us.”

Determination of DVB-T2 Signal Quality in Nigeria: A Case Study of Jos, Plateau State, Nigeria

This study presents the evaluation of digital video broadcasting-terrestrial second generation (DVB-T2) Television signal quality in Jos using Integrated Television Services Limited signal. The delivery of quality Television signal remains problematic in Nigeria due to signal attenuation and degradation between the transmitter and receiver station. This is primarily due to environmental and atmospheric perturbations prevalent along the signal paths. This research aim is to determine the signal quality of DVB-T2 Television system in Jos, Plateau State. The simple field measurement methodology was adopted in measuring field strength and channel power parameters. These measurement parameters were used to calculate for carrier-to-noise ratio (CNR) and signal-to-noise ratio (SNR) through empirical method. Finally, CNR and SNR were used to determine the signal quality of DVB-T2 signal in Jos. The result of the research shows that DVB-T2 signal in the primary service areas has good and reliable signal apart from the rocky environments.

ICT competencies for sustainability science teaching in 21st century

ICT competencies for sustainability science teaching in 21st century needs appropriate ICT competencies in order for instructional to effectiveness. The data in this study came from documentary analysis include brainstorming and interview among the science teachers of primary and secondary education service areas under the basic education commission office. ICT competencies for demonstrating knowledge and skills using technology, training the learners use technology by themselves, creating to interactive and discovery learning, technology access of connects and communicates, use ICT skills in developing and presenting of informations, designing in effective learning to experiences and creating to rich learning environments, and using ICT as didactical tool to implements the collaborative learning.

Reference Satellite Strategic Methods to Improve Position Accuracy of Rover with Resolved Integer Ambiguities Using Linear Combination in DIRNSS System

IRNSS is a regional system designed to procure, an accurate user position in all circumstances with 24/7 coverage. This system is used in a wide range of applications with accuracy better than 20 meters in the primary service area. The IRNSS provided position, velocity, and timing services are useful for the Indian users and also the users 1500km from the Indian frontier. The accurate positioning in the phase measurement technique depends on the resolution of ambiguities. In this paper, the main focus is on the effective resolution of ambiguities and thereby position estimation. This paper proposes a Carrier Phase (CP) differencing based Wide Lane (WL) measurement. To resolve the ambiguities, estimate the position of the WL classified methods, Single Frequency Single Difference (SFSD), Single Frequency Double Difference (SFDD), Dual Frequency Single Difference (DFSD), and Dual Frequency Double Difference (DFDD) are used. These four types are processed through the Reference Base and Reference Satellite (RBARS) algorithm to estimate the position of the user/rover. In this paper, direct amalgamate of three estimations are utilized: WL, Narrow Lane (NL), and Ionosphere Free (IF) carrier phase estimations. Using this combination, the estimations of ambiguities are determined for individual satellites by utilizing WL and NL techniques. Thereby the user/rover position is computed, by assessing these real number ambiguities. In this work, every single condition is utilized and together with the least-squares modifications, the positional errors are computed in 3D plane. The computed root mean square errors are compared for all classified methods.

The Role of Telemedicine in Providing Nephrology Care in Rural Hospitals

Rural hospitals rarely have the capacity and expertise to deliver timely and appropriate care for patients with ESKD because providing effective dialysis care requires a staff nephrologist readily available to coordinate care for patients on dialysis as well as proper infrastructure for water treatment systems and dialysis equipment. For these reasons, clinicians in rural hospitals typically transfer patients requiring dialysis to other, larger hospitals, sometimes hundreds of miles away. These transfers reflect broader deficits in access to timely and effective specialty care services, and may lead to poorer outcomes for rural residents (1). An analysis of the hospital admission data from the state of Georgia revealed that almost all patients with ESKD were admitted to regional or tertiary care hospitals, even when the patient resides in the primary service area of a nearby rural hospital (J. Tannenbaum, J. Lea, D. Brunn, unpublished data). Telemedicine is the delivery of healthcare services using information and communication strategies for the exchange of valid data for the diagnosis and treatment of disease to advance the health of individuals in remote areas (2,3). Tele-nephrology uses these technologies to provide care to patients with kidney disease. Asynchronous telehealth occurs when medical data are transmitted between participants for assessment when convenient and oftentimes uses remote monitoring devices such as BP monitors. This store-and-carry-forward telehealth method in the form of e-consults (electronic clinician-to-clinician communications) has been the most used form of tele-nephrology in ambulatory settings (4) and has the potential to overcome limited specialist availability, travel distance, and other barriers to expert specialty care for rural residents. In nephrology, active United States–based telehealth programs include those in specialized populations, such as veterans and the Zuni tribe in New Mexico, and others primarily in outpatient clinic settings (4–⇓⇓⇓8). However, there is very …

Abstract 351: Size Matters: Saving the Penumbra

Background: New Hanover Regional Medical Center (NHRMC) is a DNV-GL certified Comprehensive Stroke Center with its primary service area encompassing the seven-county region of Southeastern North Carolina. As the stroke hub of our region, the organization recognized the need to create a highly functional stroke center to provide optimal care to our community.In 2017, we began our comprehensive journey to include endovascular treatment of patients with large vessel occlusions. Based on the success of the Code Stroke response, which decreased door to needle times, Code ELVO (Emergent Large Vessel Occlusion) was layered in resulting in a seamless process. Objectives: The team completed a value-stream analysis by examining each step in the process. The stroke team care goals were to:•Increase the percentage of eligible stroke patients who received treatment with alteplase•Decrease the median time to treatment below the AHA/ASA “Get With the Guidelines” standards•Achieve Door to recanalization below the AHA/ASA “Get With the Guidelines” standards•Improve stroke systems of care in the region. Methods: 1. Use of Lean problem solving and PDSA methodology to identify opportunities for improvement and implement countermeasures 2. Creation of interdisciplinary team for oversight and continuous process improvements 3. Code Stroke/Code ELVO processes were developed and are continuously evaluated for improvement 4. Weekly Stroke Huddle: Representatives from the interdisciplinary stroke team gather to review cases, identify opportunities for improvement, and celebrate successes. 5. Stroke Steering Committee: Interdisciplinary committee that meets monthly to review Code Stroke, Code ELVO, and acute cerebrovascular data including quality metrics, treatments and mortality. Results: The number of patients who were treated with alteplase significantly increased 5-fold (547%), from 30 patients per year (2014) to 194 patients (2019). During this period, median alteplase treatment times were reduced by 51%, from 63 minutes (2014) to 31 minutes (2019). The percentage of patients who received alteplase in 45 minutes or less at NHRMC was 76% from 2016 - October 2019, compared to 44% nationally participating in the AHA/ASA Get with the Guideline Stroke registry. Risk adjusted mortality rate during the same period was 4.9% for NHRMC, 5.6% for all hospitals. Bleeding complications from alteplase were 3.2% for NHRMC, 4.1% nationally. The number of patients who were treated with mechanical thrombectomy significantly increased by 61% from 53 patients in 2017 to 137 patients in 2019. During this period, median door to recanalization times were reduced by 5%, from 80 minutes (2017) to 76 minutes (2019). During this period, we expanded to 24/7 coverage, extended the treatment window, and added a cerebrovascular neurosurgeon to the team.

Reducing medical student debt: 12 practical tips for innovative service commitment awards.

This article was migrated. The article was marked as recommended. At Geisinger Commonwealth School of Medicine (GCSOM), we are developing strategies to reduce the rising debt of our medical students. During a collaborative and iterative process that involved a surprisingly wide group of stakeholders, we developed an innovative service commitment award for medical students: the Abigail Geisinger Scholars Program. Beginning in spring 2019, GCSOM selected 10 current medical students for the program, and an additional 10 medical students from the class of 2023 will receive the award beginning in fall 2019. With 20 students enrolled in the Abigail Geisinger Scholars Program, student debt for these students will be decreased by approximately $3.9 million. The potential of this program to significantly reduce medical student debt while mitigating the physician shortage in the primary service areas of Geisinger is tremendous. As the loan debt of medical students continues to rise, medical schools around the country should strategically think about innovative ways to reduce this burden while remaining true to the mission of their institution.

Reducing medical student debt: 12 practical tips for innovative service commitment awards

This article was migrated. The article was marked as recommended. At Geisinger Commonwealth School of Medicine (GCSOM), we are developing strategies to reduce the rising debt of our medical students. During a collaborative and iterative process that involved a surprisingly wide group of stakeholders, we developed an innovative service commitment award for medical students: the Abigail Geisinger Scholars Program. Beginning with the spring 2019, GCSOM selected 10 current students for the program, and an additional 10 medical students from the class of 2023 will receive the award beginning in fall 2019. With 20 students enrolled in the Abigail Geisinger Scholars Program, student debt for these students will be decreased by approximately $3.9 million. The potential of this program to significantly reduce medical student debt while repopulating the physician shortage in the primary service areas of Geisinger is tremendous. As the loan debt of medical students continues to rise, medical schools around the country should strategically think about innovative ways to reduce this burden while remaining true to the mission of their institution.

Using Epidemiology, Pediatric Medical Director and Peer Review to Inform Quality Improvement and Education in a Regional Adult and Pediatric Trauma Based Flight Program

Background/Aim: Pediatric patients account for only 7 % of ground EMS transports and aeromedical transports are rare with limited research and data. When helicopter transport occurs it is commonly provided by neonatal-pediatric teams focusing on interfaciltiy transports and limited scene flights. Project target population includes transports of children 0-≤ 18 years from a critical care air transport service of three rotor wing aircraft bases including scene, interfaciltiy, trauma and medical. Each base has a primary service area within overlapping 150 nautical-mile radius covering 15,000 square-miles …

Abstract 128: The Impact of Hospital Acquisition by a Health System on Admission Allocation

Background: The optimal choice of hospital for a particular patient’s admission depends on many factors and many reasons may explain why a patient might not be admitted to the hospital that is best able to meet their needs (e.g. incomplete information about the patient, payment incentives, hospital capacity and hospital affiliation of the clinician making the hospital selection decision). Health systems that include both teaching and community hospitals should be well positioned to improve the allocation of patients to the most appropriate care setting - triaging complex patients or those with serious illnesses to teaching hospitals while triaging healthier patients or those with less severe illnesses to community hospitals. The aim of this study is to determine the impact of health system organization on the allocation of patients with common cardiovascular conditions. Methods: Using a difference in differences model, we estimated the proportion of admissions originating from a hospital’s primary service area (PSA) before and after acquisition by a health system. We then stratified patients based on the reason for admission and severity of illness. Admissions were classified as “emergent” or life-threatening, “urgent” requiring prompt medical attention but not immediately life-threatening or “elective.” Most cardiology admissions were emergent (i.e. acute coronary syndrome, shock) or urgent (i.e. heart failure exacerbation). Results: Overall, patients who lived in the PSA of a community hospital were 1% more likely to be admitted to a teaching hospital after their community hospital was acquired by a health system that included a teaching hospital. When stratified by admission type, this effect was most pronounced for urgent admissions where patients were 11.3% (p&lt;0.001) more likely to be admitted to a teaching hospital (versus their local community hospital) after acquisition of the community hospital by a health system that included a teaching hospital. Elective admissions were also 1.5% (p&lt;0.01) more likely to occur at the teaching hospital after acquisition of the community hospital by a health system that included a teaching hospital. The acquisition of a community hospital by a health system that included a teaching hospital had no impact on the distribution of emergency (life-threatening) admissions. Conclusions: Acquisition of a community hospital by a health system that includes a teaching hospital increased the rate of urgent and elective admissions from the community to a teaching hospital. The was particularly true for urgent admissions, including many cardiology admissions. The impact of this trend on patient outcomes and the cost of care merits future study.

The evaluation of IRNSS/NavIC system’s performance in its primary and secondary service areas–data quality, usability and single point positioning

The Navigation with Indian Constellation (NavIC), also known as Indian regional navigation satellite system, is a regional navigation satellite system recently developed by India. Its service area covers from 30°E to 130°E and from 30°S to 50°N. In this contribution, an assessment of NavIC from aspects of data quality, usability and single point positioning (SPP) performance is carried out using real measured data collected from four sites both within NavIC’s primary and secondary service areas. Data quality of NavIC’s signal is assessed measuring its carrier-to-noise-density ratio and each satellite’s orbital period is calculated using its broadcast ephemeris. Visible satellite number and DOPs values of each site in modes of NavIC-only, GPS-only and GPS/NavIC are counted and calculated respectively. SPP solutions in modes of NavIC-only, GPS-only and GPS/NavIC are also carried out for these four sites. The results show that: the signal strength of NavIC’s L5 frequency generally equals that of GPS in site IISC (Fig. 1); mean orbital periods of IGSO and GEO satellites are 86160.70 s and 86152.03 s respectively; in site IISC (within the primary service area), currently NavIC system can provide an independent positioning service with an accuracy of less than 1 m in the east direction and less than 2 m in north and up directions respectively; the usability and SPP performance can be improved significantly in the mode of GPS/NavIC compared with those in either single mode.

Job stress in users of an Employee Assistance Program and association with presenting status

Job stress is a top source of distress for many and one of the reasons why workers seek help through their Employee Assistance Program (EAP). Little is known about the prevalence of job stress in EAP users and its relationship with presenting status at time of program access. In this study, slightly over one third (34.5%) of a sample of at-work employees (N = 322) accessing their assistance program through an external EAP vendor reported experiencing job stress. The top reported stressors were those related to job demands and relations, followed by job features. EAP users experiencing job stress reported lower work engagement, health, and quality of life, as well as increased work distress relative to other EAP users. Notably, only this group of EAP users reported a negative health change in the last year. The number of job stressors also had a cumulative negative effect on all but one measure. The primary service area for the greater majority of EAP users was however not work-related, and most sought help for another area. Greater promotion of the use of EAPs to address work-related issues may consequently help to improve employee health and performance. Assessments of working conditions by EAP providers may also help inform the delivery of organizational-level assistance aimed at enhancing the workplace environment.

You Are About to Enter Another Dimension: The Medical Twilight Zone

You Are About to Enter Another Dimension: The Medical Twilight Zone

Vaccine-Preventable Diseases Requiring Hospitalization.

Plain children often have lower immunization rates than non-Plain children. Penn State Health Children's Hospital is a tertiary medical center with large nearby Plain (Amish and Mennonite) communities. We sought to describe the characteristics of children hospitalized with vaccine-preventable diseases (VPDs). We hypothesized that Amish children would have a higher risk of VPDs than non-Amish children. International Classification of Diseases, Ninth Revision codes were used to identify patients <18 years diagnosed with a VPD from January 1, 2005, to December 31, 2015, at Penn State Children's Hospital. Demographic information, immunization status, and outcomes were obtained from medical records. By using the number of children in our primary service area, we calculated the risk of VPD requiring hospitalization for Amish and non-Amish children. We assessed the relationship between Plain affiliation and vaccination status by using the Pearson correlation coefficient. There were 215 children with 221 VPDs. Most occurred in non-Plain children: 179 of 221 (81%). Except for pneumococcal infections, VPD occurred mostly in unvaccinated or immunocompromised children, regardless of Plain affiliation. There were 15 Haemophilus influenzae type b and 5 tetanus infections that occurred in children with an unvaccinated or unknown vaccination status. The risk of a VPD requiring hospitalization was greater for Amish than for non-Plain children (risk ratio: 2.67 [95% confidence interval: 1.87-3.82]). There was a strong correlation between Plain affiliation and lack of vaccination (r = -0.63, P < .01). Amish children had an increased risk of a VPD requiring hospitalization than non-Plain children. With the exception of those with pneumococcal disease, most vaccinated children hospitalized with a VPD were immunocompromised.