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Burns RR, Alpern ER, Rodean J, Canares T, Lee BR, Hall M, Montalbano A. Factors Associated With Urgent Care Reliance and Outpatient Health Care Use Among Children Enrolled in Medicaid. JAMA Netw Open 2020; 3:e204185. [PMID: 32374396 PMCID: PMC7203605 DOI: 10.1001/jamanetworkopen.2020.4185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/04/2020] [Indexed: 11/30/2022] Open
Abstract
Importance Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. Objectives To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. Design, Setting, and Participants A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. Exposures Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services. Main Outcomes and Measures Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. Results Of 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. Conclusions and Relevance High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.
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Affiliation(s)
- Rebecca R. Burns
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Jonathan Rodean
- Division of Analytics, Children’s Hospital Association, Lenexa, Kansas
| | - Therese Canares
- Division of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian R. Lee
- Health Outcomes and Health Services Research, Children’s Mercy, Kansas City, Missouri
| | - Matt Hall
- Division of Analytics, Children’s Hospital Association, Lenexa, Kansas
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A Predictive Model for Identification of Children at Risk of Subsequent High-Frequency Utilization of the Emergency Department for Asthma. Pediatr Emerg Care 2020; 36:e85-e89. [PMID: 31181024 PMCID: PMC6895410 DOI: 10.1097/pec.0000000000001866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Asthma is the most common chronic condition among children with high-frequency emergency department (ED) utilization. Previous research has shown in outpatients seen for asthma that acute care visits predict subsequent health care utilization. Among ED patients, however, the optimal method of predicting subsequent ED utilization remains to be described. The goal of this study was to create a predictive model to identify children in the ED who are at risk of subsequent high-frequency utilization of the ED for asthma. METHODS We used 3 years of data, 2013-2015, drawn from the electronic health records at a tertiary care, urban, children's hospital that is a high-volume center for asthma care. Data were split into a derivation (50%) and validation/test (50%) set, and 3 models were created for testing: (1) all index patients; (2) removing patients with complex chronic conditions; and (3) subset of patients with in-network care on whom more clinical data were available. Each multivariable model was then tested in the validation set, and its performance evaluated by predicting error rate, calculation of a receiver operating characteristic (ROC) curve, and identification of the optimal cutpoint to maximize sensitivity and specificity. RESULTS There were 5535 patients with index ED visits, of whom 2767 were in the derivation set and 2768 in the validation set. Of the 5535 patients, 125 patients (2.3%) had 4 or more visits for asthma in the outcome year. Significant predictors in models 1 and 2 were age and number of prior ED visits for asthma. For model 3 (additional clinical information available), the predictors were number of prior ED visits for asthma, number of primary care visits, and not having a controller medication. Areas under the ROC curve were 0.77 for model 1, 0.80 for model 2, and 0.77 for model 3. CONCLUSIONS Administrative data available at the time of ED triage can predict subsequent high utilization of the ED, with areas under the ROC curve of 0.77 to 0.80. The addition of clinical variables did not improve the model performance. These models provide useful tools for researchers interested in examining intervention efficacy by predicted risk group.
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Hsia RY, Mannix RC, Guo J, Kornblith AE, Lin F, Sokolove PE, Manley GT. Revisits, readmissions, and outcomes for pediatric traumatic brain injury in California, 2005-2014. PLoS One 2020; 15:e0227981. [PMID: 31978188 PMCID: PMC6980591 DOI: 10.1371/journal.pone.0227981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/04/2020] [Indexed: 01/23/2023] Open
Abstract
Long-term outcomes related to emergency department revisit, hospital readmission, and all-cause mortality, have not been well characterized across the spectrum of pediatric traumatic brain injury (TBI). We evaluated emergency department visit outcomes up to 1 year after pediatric TBI, in comparison to a referent group of trauma patients without TBI. We performed a longitudinal, retrospective study of all pediatric trauma patients who presented to emergency departments and hospitals in California from 2005 to 2014. We compared emergency department visits, dispositions, revisits, readmissions, and mortality in pediatric trauma patients with a TBI diagnosis to those without TBI (Other Trauma patients). We identified 208,222 pediatric patients with an index diagnosis of TBI and 1,314,064 patients with an index diagnosis of Other Trauma. Population growth adjusted TBI visits increased by 5.6% while those for Other Trauma decreased by 40.7%. The majority of patients were discharged from the emergency department on their first visit (93.2% for traumatic brain injury vs. 96.5% for Other Trauma). A greater proportion of TBI patients revisited the emergency department (33.4% vs. 3.0%) or were readmitted to the hospital (0.9% vs. 0.04%) at least once within a year of discharge. The health burden within a year after a pediatric TBI visit is considerable and is greater than that of non-TBI trauma. These data suggest that outpatient strategies to monitor for short-term and longer-term sequelae after pediatric TBI are needed to improve patient outcomes, lessen the burden on families, and more appropriately allocate resources in the healthcare system.
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Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, United States of America
| | - Rebekah C Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States of America.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Joanna Guo
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Aaron E Kornblith
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Feng Lin
- Department of Biostatistics and Epidemiology, University of California, San Francisco, California, United States of America
| | - Peter E Sokolove
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Geoffrey T Manley
- Brain and Spinal Injury Center (BASIC), University of California, San Francisco, California, United States of America.,Department of Neurological Surgery, University of California, San Francisco, California, United States of America
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Loewy J, Goldsmith C, Deshpande S, Sun A, Harris J, van Es C, Zvi ZB, Dahmer S. Music therapy in pediatric asthma improves pulmonary function while reducing hospitalizations. J Asthma 2020; 58:674-682. [PMID: 31906748 DOI: 10.1080/02770903.2020.1712725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: The aim of this study was to evaluate music therapy (MT), in conjunction with standard care, as a complementary option for asthma management in pediatric patients.Methods: 173 children were randomly assigned to one of three groups: 1) Music: a single individualized MT session along with a recorder and journal with instructions for home use; 2) Music Plus: weekly group MT sessions along with a recorder and journal for home use; or 3) Control: standard of care. Primary endpoints included pulmonary function tests (FEV1, FVC, FEF25-75, PEF), hospitalizations, ER visits, missed school days, and quality of life (Juniper).Results: Significant intergroup differences relative to Controls were observed for FEV1/FVC (Music and Music Plus, p < 0.05) and FEF25-75 (Music Plus; p < 0.01). Music Plus participants experienced fewer hospitalizations compared to Controls (p < 0.001), corresponding to 1.16 fewer hospitalizations per patient-year. Caregivers' perception of their children's QOL significantly increased in the Music (p = 0.011) and Music Plus (p < 0.001) groups compared to Controls.Conclusion: These results reflect MT's potential to favorably impact pediatric asthma management as a child-friendly, low-risk intervention. Further research is needed to substantiate the possible benefits of incorporating MT into standard treatment regimens.
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Affiliation(s)
- Joanne Loewy
- Louis Armstrong Center for Music and Medicine, Mount Sinai Beth Israel, New York City, NY, USA
| | - Cody Goldsmith
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Saarang Deshpande
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Alec Sun
- Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY, USA
| | - Jennifer Harris
- Medicine, Peninsula College of Medicine and Dentistry, Plymouth, UK
| | - Cindy van Es
- Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY, USA
| | - Zvi Ben- Zvi
- Louis Armstrong Center for Music and Medicine, Mount Sinai Beth Israel, New York City, NY, USA
| | - Stephen Dahmer
- Louis Armstrong Center for Music and Medicine, Mount Sinai Beth Israel, New York City, NY, USA
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Ramgopal S, Mazzarini A, Martin-Gill C, Owusu-Ansah S. Prehospital management of pediatric asthma patients in a large emergency medical services system. Pediatr Pulmonol 2020; 55:83-89. [PMID: 31626398 DOI: 10.1002/ppul.24542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/23/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Asthma is a common pediatric diagnosis for emergency medical services (EMS) transports, however there is a paucity of data on prehospital asthma management. The purpose of this study was to describe prehospital management of pediatric patients with suspected asthma exacerbation. METHODS We conducted a retrospective review of electronic medical records from 24 ground EMS agencies in Southwestern Pennsylvania between 1 January 2014 to 31 December 2017. We identified patients 2 to 17 years with documented wheezing, excluding those with suspected anaphylaxis. Patients with documented respiratory distress were classified as severe asthma. We report descriptive statistics of demographics, vital signs, and management including administration of medications and performance of procedures. RESULTS Of 19 246 pediatric transports, 1078 (5.6%) patients had wheezing. Of these, 532 (49%) met criteria for severe asthma. Patients with severe asthma were more likely to be adolescents compared to those with nonsevere asthma (49.6% vs 6%; P < .001). While rates of intravenous methylprednisolone administration were higher in patients with severe asthma (68/532, 12.8%) compared to those with nonsevere asthma (13/546, 2.4%; P < .001), overall use of steroids was low (7.5%). Other therapies provided included albuterol (n = 699, 64.8%), ipratropium bromide (n = 271, 25.1%), and oxygen (n = 280, 26.0%). One hundred eighty patients (16.7%) received a peripheral IV line. Two patients (0.4%) were given continuous positive airway pressure. CONCLUSION Approximately 6% of pediatric EMS transports are for asthma. Steroid usage was low in even those with severe asthma, representing an area of process improvement. These data provide a baseline to future research to identify interventions that may improve outcomes.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, Illinois
| | - Angelica Mazzarini
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians. Pediatr Emerg Care 2020; 36:16-20. [PMID: 31851079 DOI: 10.1097/pec.0000000000002015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. OBJECTIVE To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. METHODS A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. RESULTS Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). CONCLUSIONS In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.
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Axson SA, Giordano NA, McDonald CC, Pinto-Martin JA. Opioid Prescribing to Adolescents upon Discharge from an Admission of 48 Hours or Less. JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE 2019. [DOI: 10.1080/1067828x.2019.1679688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sydney A. Axson
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Catherine C. McDonald
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer A. Pinto-Martin
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Forestier A, Gehri M, Guilbaud O, Ramelet AS. Emergency consultations for male adolescents: Somatic and psychological characteristics and profiles of regular users. A retrospective chart review. Arch Pediatr 2019; 26:393-399. [PMID: 31630901 DOI: 10.1016/j.arcped.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/28/2019] [Accepted: 08/02/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Male adolescents' mental health has been understudied compared to their female counterparts and is not well known among health professionals. This is particularly problematic in emergencies because the number of such patients is increasing. OBJECTIVES To identify the type of demand for care and the characteristics of male adolescents' emergency room visits. To describe the sociodemographic data and clinical characteristics of regular users. METHOD This is a retrospective study of all medical records of male adolescents aged 14-18, admitted between 2014 and 2015 to the pediatric emergency room of a Swiss university hospital. Sociodemographic and clinical data (e.g., degree of urgency, diagnosis, length of stay, emergency service use, and emergency discharge destinations) were collected. Descriptive and multivariate analyses were performed using STATA 13.1 software. RESULTS Over the 2-year study period, 2045 male adolescents consulted in emergency departments for a total of 3199 admissions. The average age was 15.6 years (SD, 1). Most consultations were non-urgent (93%) and the reasons included musculoskeletal (43%), dermatological (13%), and digestive (10%) complaints. Forty-two male adolescents (2%) had four or more visits within the 2-year period and were considered regular users; they were also more likely to have psychological complaints (adjusted OR, 5.04; 95% CI, 1.81-13.72) and comorbidities (adjusted OR, 2.55; 95% CI, 1.25-5.21) when compared to their counterparts with fewer than four visits. CONCLUSION Since regular users are at greater risk of having psychological complaints and comorbidities during their first emergency room visit, a systematic assessment of these adolescents' mental health levels and overall health indicators is recommended.
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Affiliation(s)
- A Forestier
- University institute of higher education and research in healthcare, Biopôle 2, route de la Corniche 10, 1010 Lausanne, Switzerland; School of health sciences, Avenue de Champel 47, 1206 Geneva, Switzerland.
| | - M Gehri
- Department woman, mother, child, University Hospital of Lausanne, Rue du Bugnon, 1010 Lausanne, Switzerland
| | - O Guilbaud
- University hospital of Lausanne, service universitaire de psychiatrie de l'enfant et de l'adolescent (SUPEA), 1010 Lausanne, Switzerland
| | - A S Ramelet
- University institute of higher education and research in healthcare, Biopôle 2, route de la Corniche 10, 1010 Lausanne, Switzerland
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Andrews AL, Brinton DL, Simpson KN, Simpson AN. A Longitudinal Examination of the Asthma Medication Ratio in Children with Medicaid. J Asthma 2019; 57:1083-1091. [PMID: 31313611 DOI: 10.1080/02770903.2019.1640727] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background/Objective: An efficient and accurate strategy for identifying children with asthma at high-risk for exacerbation is needed. The objective of this study is to conduct a longitudinal examination of the asthma medication ratio (AMR) (#of controller medication claims/(# of controller medication claims + # of rescue medication claims)) in Medicaid-funded children with asthma. This measure has the potential to be a near real-time risk assessment tool.Methods: We conducted a retrospective analysis of 2013-2014 Truven Health Medicaid data. We analyzed pharmacy and medical claims for a cohort of children with asthma. We identified patients age 2-17 years with at least one claim for an inhaled corticosteroid. We calculated an AMR for rolling 3-month periods and examined the proportion who were classified as low risk (AMR ≥ .5), high-risk (AMR < .5) and no medication claims (no asthma medication claims). Using logistic regression, we tested how the AMR predicted severe exacerbations.Results: 214,452 eligible children were identified. The mean age is 7.8 years. 8-9% had a high-risk AMR in any given period. High-risk AMR is associated with increased odds of a severe exacerbation in the subsequent 3 months (compared to all other children) (OR 1.7-1.9 depending on time period evaluated).Conclusions: In this analysis of Medicaid-insured children with asthma, we found that the AMR is a reliable predictor of exacerbations. This will inform the development of an AMR-based risk assessment and communication intervention.
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Affiliation(s)
- Annie Lintzenich Andrews
- Department of Pediatrics, College of Medicine, Medical, University of South Carolina, Charleston, SC, USA
| | - Daniel L Brinton
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Annie N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
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Gjelsvik A, Rogers ML, Garro A, Sullivan A, Koinis-Mitchell D, McQuaid EL, Smego R, Vivier PM. Neighborhood Risk and Hospital Use for Pediatric Asthma, Rhode Island, 2005-2014. Prev Chronic Dis 2019; 16:E68. [PMID: 31146802 PMCID: PMC6549429 DOI: 10.5888/pcd16.180490] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Studies consistently show that children living in poor neighborhoods have worse asthma outcomes. The objective of our study was to assess the association between negative neighborhood factors (ie, neighborhood risk) and pediatric asthma hospital use. METHODS This retrospective study used data from children aged 2 to 17 years in a statewide (Rhode Island) hospital network administrative database linked to US Census Bureau data. We defined an asthma visit as an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code of 493 in any diagnosis field. We used 8 highly correlated measures for each census-block group to construct an index of neighborhood risk. We used maps and linear regression to assess the association of neighborhood risk with average annual census-block-group rates of asthma emergency department visits and hospitalizations. We used multivariable analyses to identify child characteristics and neighborhood risk associated with an asthma revisit, accounting for the child's sociodemographic information, season, and multiple measurements per child. RESULTS From 2005 through 2014, we counted 359,195 visits for 146,889 children. Of these, 12,699 children (8.6%) had one or more asthma visits. Linear regression results showed 1.18 (95% confidence interval, 1.06-1.30) more average annual emergency departments visits per 100 children and 0.41 (95% confidence interval, 0.34-0.47) more average annual hospitalizations per 100 children in neighborhoods in the highest-risk index quintile than in neighborhoods in the lowest-risk index quintile. CONCLUSION Interventions to improve asthma outcomes among children should move beyond primary care or clinic settings and involve a careful evaluation of social context and environmental triggers.
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Affiliation(s)
- Annie Gjelsvik
- Department of Epidemiology, Brown University, Providence, Rhode Island
- Hassenfeld Child Health Innovation Institute, Providence, Rhode Island
- Brown University, Box G-121S, Providence, RI 02912.
| | - Michelle L Rogers
- Hassenfeld Child Health Innovation Institute, Providence, Rhode Island
| | - Aris Garro
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Pediatrics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Adam Sullivan
- Hassenfeld Child Health Innovation Institute, Providence, Rhode Island
- Department of Biostatistics, Brown University, Providence, Rhode Island
| | - Daphne Koinis-Mitchell
- Hassenfeld Child Health Innovation Institute, Providence, Rhode Island
- Department of Pediatrics, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island
| | - Elizabeth L McQuaid
- Hassenfeld Child Health Innovation Institute, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island
| | - Raul Smego
- Hassenfeld Child Health Innovation Institute, Providence, Rhode Island
| | - Patrick M Vivier
- Hassenfeld Child Health Innovation Institute, Providence, Rhode Island
- Department of Pediatrics, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
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Chiu Y, Racine-Hemmings F, Dufour I, Vanasse A, Chouinard MC, Bisson M, Hudon C. Statistical tools used for analyses of frequent users of emergency department: a scoping review. BMJ Open 2019; 9:e027750. [PMID: 31129592 PMCID: PMC6537981 DOI: 10.1136/bmjopen-2018-027750] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user. METHODS We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis. RESULTS We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used. CONCLUSIONS This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.
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Affiliation(s)
- Yohann Chiu
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - François Racine-Hemmings
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Isabelle Dufour
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alain Vanasse
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Increasing Trichomonas vaginalis testing for high-risk adolescents a pediatric emergency department. Pediatr Qual Saf 2019; 4:e140. [PMID: 31321360 PMCID: PMC6494222 DOI: 10.1097/pq9.0000000000000140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/28/2018] [Indexed: 11/25/2022] Open
Abstract
Background Trichomonas is a common sexually transmitted infection (STI) among adolescents, causing vaginal discharge, pelvic pain, and dysuria. Affected individuals have increased susceptibility to other STIs and may have pregnancy complications. A quality improvement project was developed to increase trichomonas testing among high-risk adolescent patients from 40% in July 2014 to 100% by December 31, 2014, and sustain over 6 months. Methods An interdisciplinary team (providers and support staff) was assembled to address this objective. We collected 6 months of baseline data. Deploying the Institute for Healthcare Improvement Model for Improvement, we formulated an aim statement and identified key drivers. We used cause analysis to identify interventions for each problem area. Multiple Plan-Do-Study-Act cycles were undertaken, and results were monitored using control charts. Interventions included increasing awareness and education for clinical staff; changing computer order entry for the test; using order sets for STI; and adding a Licensed Professional Initiated Protocol to nurse ordering practice. These interventions were all done in conjunction with feedback to providers for individual missed cases. Results Over 18 months, the trichomonas testing rate rose with each intervention: from 25% (January 2014) to 98% (December 2014), which we have sustained through June 2015. Implications and Contributions This article demonstrates the successful use of quality improvement methodology to increase rates of Trichomonas vaginalis testing among at-risk adolescent patients. Increased testing results in increased detection and improved treatment and sexual health for our patients. Conclusion Improving the trichomonas testing process in the pediatric emergency department results in higher screening rates among high-risk adolescent patients.
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A review of racial/ethnic disparities in pediatric trauma care, treatment, and outcomes. J Trauma Acute Care Surg 2019; 86:540-550. [DOI: 10.1097/ta.0000000000002160] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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64
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Dotson JL, Kappelman MD, Bricker J, Andridge R, Chisolm DJ, Crandall WV. Multicenter Evaluation of Emergency Department Treatment for Children and Adolescents With Crohn's Disease According to Race/Ethnicity and Insurance Payor Status. Inflamm Bowel Dis 2019; 25:194-203. [PMID: 29850811 DOI: 10.1093/ibd/izy192] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Racial and socioeconomic disparities exist in the treatment and outcomes of children and adults with Crohn's disease (CD). This study investigated the impact of race and insurance status on emergency department (ED) evaluation and treatment among children with CD in the United States. METHODS Data from the Pediatric Health Information System included ED visits between January 2007 and December 2013 for patients aged ≤21 years with a primary diagnosis of CD, or a secondary diagnosis of CD plus a primary CD-related diagnosis. Analyses were performed using mixed-effects logistic regression. RESULTS Subjects included 2618 unique patients (black, 612 [23%]; white, 2006 [77%]) with 3779 visits from 38 hospitals, a median age of 14.0 ± 4.0 years, and 50% male. White children had a higher median neighborhood income and were more likely to have private insurance (57% vs 30%; P < 0.001). Emergency department visits for privately insured patients had higher odds of complete blood count (odds ratio [OR], 1.43; 95% CI, 1.08-1.90) and C-reactive protein/erythrocyte sedimentation rate (OR, 1.39; 95% CI, 1.06-1.82) vs Medicaid insured. Visits for white children had higher odds of receiving antiemetics (OR, 1.52; 95% CI, 1.06-2.17) vs black children. The proportion of patients with repeat visits was greater for black children (33%) than white children (22%; P < 0.001) and greater for Medicaid-insured (27%) than privately insured patients (21%; P < 0.01). CONCLUSIONS This cross-sectional database study demonstrated that black children and those with Medicaid insurance made more ED visits and received somewhat fewer treatments, which may be explained by greater use of the ED for routine care. An opportunity exists for better outpatient management of children with IBD so that nonemergent problems are more effectively handled.
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Affiliation(s)
- Jennifer L Dotson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition.,The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael D Kappelman
- University of North Carolina at Chapel Hill, Department of Pediatrics, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina
| | - Josh Bricker
- The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Rebecca Andridge
- Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Deena J Chisolm
- The Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
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Riddle S, Meinzen-Derr J, Tabangin M, Woodward J, Wiley S. Emergency department utilization among pediatric spina bifida patients. J Pediatr Rehabil Med 2019; 12:375-381. [PMID: 31744029 PMCID: PMC8011457 DOI: 10.3233/prm-180561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE There is a gap in knowledge regarding the use of emergency services by pediatric spina bifida patients. The goal of this study was to describe Emergency Department utilization patterns in this population. METHODS Through a retrospective observational study, patients with spina bifida who visited the emergency department during a four-year period were identified; medical and demographic information was obtained though the Centers for Disease Control National Spina Bifida Patient Registry. Chief complaints and final diagnoses of visits were classified and related to medical needs of spina bifida to determine the appropriate care level. RESULTS Among 303 children within the registry, 161 patients (53%) accounted for 579 visits. 70% of visits were for spina bifida-related complaints. Approximately half (51.7%) had a shunt-related chief complaint, although final diagnosis was largely unrelated to the shunt. Admission rate was 39%, higher than institutional baseline, and largely represented by genitourinary (GU) complaints. CONCLUSION Pediatric patients with spina bifida presenting to a single center emergency department were most likely to present with shunt and urinary concerns; these patients were most likely to be admitted. This potentially suggests that improving outpatient care for bladder management may decrease emergency department use among this population.
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Affiliation(s)
- Stefanie Riddle
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Jareen Meinzen-Derr
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Meredith Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jason Woodward
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Susan Wiley
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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Supat B, Brennan JJ, Vilke GM, Ishimine P, Hsia RY, Castillo EM. Characterizing pediatric high frequency users of California emergency departments. Am J Emerg Med 2018; 37:1699-1704. [PMID: 30651182 DOI: 10.1016/j.ajem.2018.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Emergency department (ED) utilization has increased for the last several decades. Despite a focus on adult frequent ED users, little research has examined pediatric frequent ED users. The purpose of this study was to assess pediatric ED utilization in California and to describe those identified as frequent ED users. METHODS This was a retrospective multi-facility study of ED visits by children 1-17 years of age using statewide data from the California Office of Statewide Health Planning and Development. Patients were classified into utilization groups by the number of ED visits in a one-year period prior to their last visit in 2016: occasional (1-5 visits) vs. frequent (>5 visits). Differences in patient characteristics were compared between occasional and frequent users. RESULTS There were 690,130 patients between 1 and 17 years of age with 1,238,262 visits during the study period. Children with ≥6 visits (2.3%) accounted for 9.3% of all visits. 67% of frequent users had no visits to a pediatric ED. Over 40% (41.4%) of frequent users visited 2 or more hospitals, compared to 7.7% of occasional users. In multivariate analysis, the characteristics with the largest associations with frequent ED use were age, payer, and being admitted/transferred. CONCLUSIONS The majority of pediatric frequent users do not seek care in pediatric EDs. Age, prior admission, and Medicare/Medicaid appear to have the largest associations with pediatric patient frequent ED utilization.
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Affiliation(s)
- Benjamin Supat
- Department of Emergency Medicine, University of California San Diego, 200 W Arbor Drive, San Diego, CA 92103, United States.
| | - Jesse J Brennan
- Department of Emergency Medicine, University of California San Diego, 200 W Arbor Drive, San Diego, CA 92103, United States
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego, 200 W Arbor Drive, San Diego, CA 92103, United States
| | - Paul Ishimine
- Department of Emergency Medicine, University of California San Diego, 200 W Arbor Drive, San Diego, CA 92103, United States; Department of Emergency Medicine, Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123, United States
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St, San Francisco, CA 94118, United States
| | - Edward M Castillo
- Department of Emergency Medicine, University of California San Diego, 200 W Arbor Drive, San Diego, CA 92103, United States
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Abstract
OBJECTIVES The aims of this study were to determine differences in emergency department (ED) use by Native American (NA) children in rural and urban settings and identify factors associated with frequent ED visits. METHODS This cross-sectional, cohort study examined visits to 6 EDs: 2 rural, 2 midsize urban, and 2 large urban EDs from June 2011 to May 2012. Univariate and multiple regression analyses were conducted. Frequent ED visitors had more than 4 visits in the study period. RESULTS We studied 8294 NA visits (5275 patients) and 44,503 white visits (33,945 patients). Rural EDs had a higher proportion of NA patients, those below 200% of the income poverty level, and those who traveled more than 10 miles from their residence to attend the ED (all P < 0.05) compared with midsize and urban EDs. Native American patients had a high proportion of mental health diagnoses compared with whites (4.9% vs 1.9%, P < 0.001). Frequent ED visitors had greater odds of NA race, age younger than 1 year, public insurance, female sex, residence within less than 5 miles from the ED, and chronic disease. CONCLUSIONS Native American children seem to have greater challenges compared with whites obtaining care in rural areas. Native American children were more likely to be frequent ED visitors, despite having to travel farther from their residence to the ED. Native American children visiting rural and midsize urban EDs had a much higher prevalence of mental health problems than whites. Additional efforts to provide both medical and mental health services to rural NA are urgently needed.
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Rose L, McKim D, Leasa D, Nonoyama M, Tandon A, Bai YQ, Goldstein R, Amin R, Katz S, Gershon A. Respiratory health service utilization of children with neuromuscular disease. Pediatr Pulmonol 2018; 53:1378-1386. [PMID: 30129703 DOI: 10.1002/ppul.24145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/29/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To quantify health service utilization including assessment, monitoring, and treatment of respiratory complications of children with neuromuscular disease (NMD), identifying practice variation and adherence to guideline recommendations at a population level. METHODS North American population-based cohort study (2003-2015) of children with NMD using hospital diagnostic and physician billing codes within health administrative databases. RESULTS We identified 18 163 children with NMD. Mean (SD) age was 7.8 (5.6) years with 40% ≤5; 45% were female. Most common diagnoses were cerebral palsy (50%) and spina bifida (16%); 8% had muscular dystrophy. From fiscal years 2003-2014, 15 600 (86%) children went to an emergency department on average 3.5 times every 3 years; 6575 (36%) for respiratory reasons. 8788 (48%) were admitted to hospital with 2190 (12%) for respiratory reasons and 2451 (13%) required intensive care. Respiratory specialist outpatient visits occurred for 2226 (12%) children on average 6.5 visits every 3 years; 723 (4%) had in-hospital respiratory specialist consultation. Pulmonary function testing was conducted in 3194 (18%) children on average 2.4 times every 3 years; sleep studies in 1389 (8%). CONCLUSION In this population-based study of children with NMD, healthcare utilization for respiratory complications was considerable. Frequency of respiratory specialist consultation, monitoring of respiratory function and sleep disordered breathing was variable but on average reflected professional society recommendations. Children with NMD are frequent ED users suggesting a need to improve community and social supports. We did not detect reduced access to respiratory monitoring or specialist consultation in adolescents transitioning to adult services.
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Affiliation(s)
- Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, Kings College London, Lawrence S. Bloomberg Faculty of Nursing and Faculty of Medicine, University of Toronto, Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Douglas McKim
- The Ottawa Hospital Respiratory Rehabilitation and The Ottawa Hospital Sleep Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - David Leasa
- Department of Medicine, Divisions of Critical Care and Respirology London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Mika Nonoyama
- University of Ontario Institute of Technology, Child Health Evaluative Sciences & Respiratory Therapy, SickKids, Rehabilitation Sciences & Physical Therapy, University of Toronto, Oshawa, Ontario, Canada
| | - Anu Tandon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yu Qing Bai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Roger Goldstein
- West Park Healthcare Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, SickKids, SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Sherri Katz
- Division of Respirology, Children's Hospital of Eastern Ontario, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrea Gershon
- Sunnybrook Health Sciences Centre, Sunnybrook Research Institute and the Institute of Clinical Evaluative Sciences, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Cabey WV, Shea JA, Kangovi S, Kennedy D, Onwuzulike C, Fein J. Understanding Pediatric Caretakers' Views on Obtaining Medical Care for Low-acuity Illness. Acad Emerg Med 2018; 25:1004-1013. [PMID: 29741232 DOI: 10.1111/acem.13436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 04/07/2018] [Accepted: 04/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND A significant proportion of low-acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low-acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers' perspectives. The objective of this study was to explore caretaker decision-making processes, values, and priorities when deciding to seek care. METHODS We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing. RESULTS Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision-making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low-acuity care was well received by caretakers. CONCLUSIONS Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low-acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.
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Affiliation(s)
| | - Judy A. Shea
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | - Shreya Kangovi
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | | | | | - Joel Fein
- Department of Pediatrics Perelman School of Medicine The Children's Hospital of Philadelphia Philadelphia PA
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Taylor T, Salyakina D. Health Care Access Barriers Bring Children to Emergency Rooms More Frequently: A Representative Survey. Popul Health Manag 2018; 22:262-271. [PMID: 30160608 PMCID: PMC6555172 DOI: 10.1089/pop.2018.0089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Children may visit the emergency department (ED) regularly in part because they and their caregivers may be experiencing barriers to appropriate and timely pediatric care. However, assessing the wide range of potential barriers to access to care that children and their caregivers may experience is often a challenge. The objective of this study was to assess the barriers to pediatric health care reported by caregivers and to examine the association between those reported barriers to care with the frequency of children's ED visits in the past 12 months. Assessment of ED utilization and access to care barriers was made through a telephone interview survey conducted as part of a broader Community Health Needs Assessment in 2015. A weighted community sample of adult caregivers (N = 1057) of children between the ages of 0-17 residing in Miami-Dade, Broward, and Palm Beach counties, Florida were contacted. This study found that multiple ED visits (≥2 vs. 0) in the past 12 months by a child were most strongly associated with access to care barriers attributed to language and culture (relative risk [RR] = 2.51), trouble finding a doctor (RR = 1.86), scheduling an appointment (RR = 1.68), and transportation access (RR = 1.73). These findings suggest that access to care barriers experienced by households may exacerbate the risk of a child experiencing repeated visits to the ED in a year. Findings are discussed further in the context of actionable population health management strategies to reduce risk of frequent ED utilization by children.
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Affiliation(s)
- Thom Taylor
- Nicklaus Children's Research Institute, Miami, Florida
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71
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Samuels‐Kalow ME, Faridi MK, Espinola JA, Klig JE, Camargo CA. Comparing Statewide and Single-center Data to Predict High-frequency Emergency Department Utilization Among Patients With Asthma Exacerbation. Acad Emerg Med 2018; 25:657-667. [PMID: 29105238 DOI: 10.1111/acem.13342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/11/2017] [Accepted: 10/23/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous studies examining high-frequency emergency department (ED) utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single-center data. METHODS To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single-center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike's Information Criterion scores, 10-fold cross-validation, and receiver operating characteristic curves. RESULTS Among children, high-frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10-fold cross-validation for children was 0.70 (95% confidence interval [CI] = 0.69-0.72), compared to 0.71 (95% CI = 0.69-0.72) in the single-center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76-0.77) and 0.76 (95% CI = 0.75-0.77), respectively. CONCLUSION Data available at the index ED visit can predict subsequent high-frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single-center).
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Affiliation(s)
| | - Mohammad K. Faridi
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Janice A. Espinola
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Jean E. Klig
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
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Kersten EE, Adler NE, Gottlieb L, Jutte DP, Robinson S, Roundfield K, LeWinn KZ. Neighborhood Child Opportunity and Individual-Level Pediatric Acute Care Use and Diagnoses. Pediatrics 2018; 141:peds.2017-2309. [PMID: 29626164 PMCID: PMC5991499 DOI: 10.1542/peds.2017-2309] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2018] [Indexed: 12/22/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5751513300001PEDS-VA_2017-2309Video Abstract OBJECTIVES: Although health care providers and systems are increasingly interested in patients' nonmedical needs as a means to improve health, little is known about neighborhood conditions that contribute to child health problems. We sought to determine if a novel, publicly available measure of neighborhood context, the Child Opportunity Index, was associated with pediatric acute care visit frequency and diagnoses. METHODS This cross-sectional study included San Francisco residents <18 years of age with an emergency department and/or urgent care visit to any of 3 medical systems (N = 47 175) between 2007 and 2011. Hot-spot analysis was used to compare the spatial distribution of neighborhood child opportunity and income. Generalized estimating equation logistic regression models were used to examine independent associations between neighborhood child opportunity and frequent acute care use (≥4 visits per year) and diagnosis group after adjusting for neighborhood income and patient age, sex, race and/or ethnicity, payer, and health system. RESULTS Neighborhood child opportunity and income had distinct spatial distributions, and we identified different clusters of high- and low-risk neighborhoods. Children living in the lowest opportunity neighborhoods had significantly greater odds of ≥4 acute care visits per year (odds ratio 1.33; 95% confidence interval 1.03-1.73) compared with those in the highest opportunity neighborhoods. Neighborhood child opportunity was negatively associated with visits for respiratory conditions, asthma, assault, and ambulatory care-sensitive conditions but positively associated with injury-related visits. CONCLUSIONS The Child Opportunity Index could be an effective tool for identifying neighborhood factors beyond income related to child health.
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Affiliation(s)
| | - Nancy E. Adler
- Departments of Psychiatry,,Pediatrics, and,Center for Health and Community, University of
California, San Francisco, San Francisco, California
| | - Laura Gottlieb
- Family and Community Medicine, and,Center for Health and Community, University of
California, San Francisco, San Francisco, California
| | - Douglas P. Jutte
- Division of Community Health Sciences, School of
Public Health, University of California, Berkeley, Berkeley, California;,Build Healthy Places Network, San Francisco,
California; and
| | | | | | - Kaja Z. LeWinn
- Departments of Psychiatry,,Center for Health and Community, University of
California, San Francisco, San Francisco, California
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Samuels-Kalow M, Peltz A, Rodean J, Hall M, Alpern ER, Aronson PL, Berry JG, Shaw KN, Morse RB, Freedman SB, Cohen E, Simon HK, Shah SS, Katsogridakis Y, Neuman MI. Predicting Low-Resource-Intensity Emergency Department Visits in Children. Acad Pediatr 2018; 18:297-304. [PMID: 29331346 DOI: 10.1016/j.acap.2017.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/15/2017] [Accepted: 12/30/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits. METHODS We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI. RESULTS Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74. CONCLUSIONS Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered.
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Affiliation(s)
| | - Alon Peltz
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Conn
| | | | | | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Conn
| | - Jay G Berry
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kathy N Shaw
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Rustin B Morse
- Children's Health System of Texas, Dallas, Tex; Department of Pediatrics, University of Texas Southwestern, Dallas, Tex
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harold K Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Ga
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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Sills MR, Macy ML, Kocher KE, Sabbatini AK. Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children. Acad Emerg Med 2018; 25:283-292. [PMID: 28960666 DOI: 10.1111/acem.13324] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 08/26/2017] [Accepted: 09/04/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit. METHODS This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission). RESULTS Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission. CONCLUSIONS Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.
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Affiliation(s)
- Marion R. Sills
- Departments of Pediatrics and Emergency Medicine and the Adult and Child Consortium for Outcomes Research and Delivery Science University of Colorado School of Medicine and Children's Hospital Colorado (MRS) AuroraCO
| | - Michelle L. Macy
- Department of Pediatrics University of Michigan Ann Arbor MI
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Child Health Evaluation and Research University of Michigan Ann Arbor MI
| | - Keith E. Kocher
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Amber K. Sabbatini
- Division of Emergency Medicine University of Washington Harborview Medical Center Seattle WA
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75
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Kim BS, Kim JY, Choi SH, Yoon YH. Understanding the characteristics of recurrent visits to the emergency department by paediatric patients: a retrospective observational study conducted at three tertiary hospitals in Korea. BMJ Open 2018; 8:e018208. [PMID: 29453296 PMCID: PMC5857697 DOI: 10.1136/bmjopen-2017-018208] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The number of paediatric patients visiting the emergency department (ED) continues to rise. In South Korea, approximately 25% of the patients who visit the ED are paediatric patients. In the USA, about 20% of the paediatric population were found to have visited the ED in the past year. A recent study demonstrated that 4.5%-8% of patients account for 25% of all ED visits. Therefore, the aim of this study was to identify the characteristics of recurrent visits. METHODS Design: retrospective observational study. SETTING this study examined and analysed medical record data involving three tertiary EDs. PARTICIPANTS a total of 46 237 ED visits by patients <16 years during 1-year period. MAIN OUTCOME MEASURES data collected included the number of recurrent ED patients, frequency of recurrent visits, age, sex, insurance status, period until recurrent visit (days), main diagnosis and ED discharge results. RESULTS Excluding patients with multiple visits, the total number of paediatric patients who fit the study criteria was 33 765. Among these patients, 23 384 (69.2%) had no recurrent ED visits in the subsequent year after their first visit. A total of 15 849 (46.8%) patients were toddlers (between age 1 and 4 years). In the patient group without a recurrent visit, fever was the most common diagnosis. CONCLUSIONS Our study reviewed medical records to inspect the characteristics of patients who return to care. Higher recurrent visit frequency was associated with using the 119 rescue centre service, having a medical condition, with younger age and a higher rate of hospitalisation. Analysis of the factors associated with frequent ED visits will help to improve care for paediatric patients who visit the ED.
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Affiliation(s)
- Byung-Soo Kim
- Department of Emergency Medicine, College of Medicine, KoreaUniversity, Seoul, Republic of Korea
| | - Jung-Youn Kim
- Department of Emergency Medicine, College of Medicine, KoreaUniversity, Seoul, Republic of Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, College of Medicine, KoreaUniversity, Seoul, Republic of Korea
| | - Young-Hoon Yoon
- Department of Emergency Medicine, College of Medicine, KoreaUniversity, Seoul, Republic of Korea
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76
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Fishman J, McLafferty S, Galanter W. Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions? Health Serv Res 2018; 53:489-508. [PMID: 27859257 PMCID: PMC5785320 DOI: 10.1111/1475-6773.12617] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To examine the contributions of individual- and neighborhood-level spatial access to care to the utilization of emergency departments (EDs) for preventable conditions through implementation of novel local spatial access measures. DATA SOURCES/STUDY SETTING Emergency department admissions data are from four HealthLNK member hospitals in Chicago from 2007 to 2011. Primary care physician office and clinic locations were obtained from the American Medical Association and the City of Chicago. STUDY DESIGN Multilevel logit regression was used to model the relationship between individual- and neighborhood-level attributes and preventable ED use. DATA COLLECTION/EXTRACTION METHODS Emergency department admissions data were classified based on the primary diagnosis for each encounter. Spatial access to care indices were generated in ArcGIS, and values were extracted at each ZIP code centroid to match patients' ZIP codes. PRINCIPAL FINDINGS Beyond sociodemographic factors such as gender and race, patients living in medically underserved areas (MUAs) and areas with lower spatial access to primary care clinics had higher odds of preventable ED use. CONCLUSIONS Preventable ED use can be associated with sociodemographic characteristics, as well as spatial access to primary care services. This study reveals potential for using local measures of spatial accessibility for preventable ED analyses.
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Affiliation(s)
- Jamie Fishman
- Department of Geography and Geographic Information ScienceUniversity of Illinois at Urbana‐ChampaignChicagoIL
| | - Sara McLafferty
- Department of Geography and Geographic Information ScienceUniversity of Illinois at Urbana‐ChampaignChicagoIL
| | - William Galanter
- Department of MedicineUniversity of Illinois College of Medicine at ChicagoChicagoIL
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Levine R, Javalkar K, Nazareth M, Faldowski RA, de Ferris MDG, Cohen S, Cuttance J, Hooper SR, Rak E. Disparities in Health Literacy and Healthcare Utilization among Adolescents and Young Adults with Chronic or End-stage Kidney Disease. J Pediatr Nurs 2018; 38:57-61. [PMID: 29167082 DOI: 10.1016/j.pedn.2017.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Low health literacy adversely affects health outcomes in adults with chronic kidney disease. The current study examined associations between limited/inadequate health literacy and health services utilization among adolescents and young adults (AYA) with chronic or end-stage kidney disease (CKD or ESKD). DESIGN AND METHODS This was a retrospective cohort study that enrolled patients from both the pediatric- and adult-focused nephrology clinics of a major university hospital. Demographic information, patients' health literacy and numeracy skills (Newest Vital Sign), and health services utilization (emergency department visits, preventable hospitalizations, total hospitalizations, and length of stay in the hospital) were evaluated. A negative binomial regression model for counts tested the association between AYA patients' literacy/numeracy skills and health services utilization. RESULTS The study enrolled 142 participants, 66 (46.5%) patients from adult nephrology and 76 (53.5%) from pediatric nephrology clinics, with a mean age of 20.8±5.60years (range 12-31). Half of the sample (n=72, 51%) had limited health literacy skills. Health literacy/numeracy level was not significantly associated with total hospitalizations, preventable hospitalizations, emergency department (ED) visits, or length of hospital stay. However, public insurance/self-pay, minority race, and kidney transplant/dialysis diagnoses were associated with more preventable hospitalizations. CONCLUSIONS Among AYA with CKD/ESKD, there were no differences between the low and adequate health literacy groups on health care utilization outcomes when modeling clinical outcomes (total hospitalizations, preventable hospitalizations, ED visits, and length of hospital stay) after adjusting for demographics and disease type. This suggests that other factors warrant consideration in healthcare utilization rates.
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Affiliation(s)
- Robyn Levine
- University of North Carolina School of Medicine, Department of Pediatrics, USA; Alpert Medical School of Brown University, Department of Emergency Medicine, USA
| | - Karina Javalkar
- University of North Carolina School of Medicine, Department of Pediatrics, USA
| | - Meaghan Nazareth
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, USA
| | - Richard A Faldowski
- University of North Carolina School of Medicine, Department of Allied Health Sciences, USA
| | | | - Sarah Cohen
- University of North Carolina School of Medicine, Department of Allied Health Sciences, USA
| | - Jessica Cuttance
- University of North Carolina School of Medicine, Department of Allied Health Sciences, USA
| | - Stephen R Hooper
- University of North Carolina School of Medicine, Department of Allied Health Sciences, USA
| | - Eniko Rak
- University of North Carolina School of Medicine, Department of Allied Health Sciences, USA.
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78
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Riva B, Clavenna A, Cartabia M, Bortolotti A, Fortino I, Merlino L, Biondi A, Bonati M. Emergency department use by paediatric patients in Lombardy Region, Italy: a population study. BMJ Paediatr Open 2018; 2:e000247. [PMID: 29942865 PMCID: PMC6014225 DOI: 10.1136/bmjpo-2017-000247] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/02/2018] [Accepted: 04/29/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the rate of paediatric attendance at emergency departments (EDs) in the Lombardy Region, Italy, and to determine the factors contributing to different patterns of use. METHODS By analysing healthcare administrative databases, ED attendance by 1.6 million youths <18 years old during 2012 in the Lombardy Region was assessed. The pattern of use was categorised based on the number of ED visits and level of emergency, defined by triage code and outcome of the visit. Logistic regression analyses were performed to identify the characteristics of access for non-urgent reasons and those of patients with frequent non-urgent access (≥4 accesses for non-urgent reasons only). A case-control study was carried out to compare healthcare resource use by children 1-5 years old who were 'frequent non-urgent users' with that of randomly selected controls, matched by age, gender, nationality and primary care physician. RESULTS During 2012, 440 284 (27%) of children and adolescents had at least one ED attendance, with trauma (26%) and respiratory tract infections (22%) as the most frequent diagnoses. In all, 533 037 (79%) accesses were for non-urgent reasons, and 12 533 (3% of the ED users) were frequent non-urgent users. Male gender (OR 1.12; 95% CI 1.08 to 1.17), preschool age (OR 3.14; 95% CI 2.98 to 3.31) and place of residence (OR 1.74; 95% CI 1.70 to 1.99) were associated with a higher risk of being a frequent non-urgent user. Moreover, a greater healthcare consumption was observed in this group. CONCLUSIONS One out of four children and adolescents attended the ED at least once per year, 3% of whom were frequent non-urgent users, with a high overall healthcare resource consumption.
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Affiliation(s)
- Benedetta Riva
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy.,Department of Pediatrics, Hospital S. Gerardo/Fondazione MBBM, University of Milano-Bicocca, Monza, Italy
| | - Antonio Clavenna
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - Massimo Cartabia
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | | | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Andrea Biondi
- Department of Pediatrics, Hospital S. Gerardo/Fondazione MBBM, University of Milano-Bicocca, Monza, Italy
| | - Maurizio Bonati
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
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79
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Schlichting LE, Rogers ML, Gjelsvik A, Linakis JG, Vivier PM. Pediatric Emergency Department Utilization and Reliance by Insurance Coverage in the United States. Acad Emerg Med 2017; 24:1483-1490. [PMID: 28833943 DOI: 10.1111/acem.13281] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/09/2017] [Accepted: 08/15/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care. METHODS Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits. RESULTS A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51-0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47-1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49-2.42) were more likely to be reliant on the ED than children with private insurance. CONCLUSIONS Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.
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Affiliation(s)
| | | | - Annie Gjelsvik
- Hassenfeld Child Health Innovation Institute; Providence RI
- Department of Epidemiology; Providence RI
- Department of Pediatrics; Alpert Medical School; Providence RI
| | - James G. Linakis
- Hassenfeld Child Health Innovation Institute; Providence RI
- Department of Pediatrics; Alpert Medical School; Providence RI
- Department of Emergency Medicine; Alpert Medical School; Providence RI
- Injury Prevention Center; Rhode Island Hospital; Providence RI
| | - Patrick M. Vivier
- Hassenfeld Child Health Innovation Institute; Providence RI
- Department of Pediatrics; Alpert Medical School; Providence RI
- Department of Health Services, Policy, and Practice; Brown University; Providence RI
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80
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Pickner WJ, Ziegler KM, Hanson JD, Payne NR, Zook HG, Kharbanda AB, Weber TL, Russo JN, Puumala SE. Community Perspectives on Emergency Department Use and Care for American Indian Children. J Racial Ethn Health Disparities 2017; 5:939-946. [PMID: 29101687 DOI: 10.1007/s40615-017-0442-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/21/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Abstract
Emergency department (ED) utilization by American Indian (AI) children is among the highest in the nation. Numerous health disparities have been well documented in AI children, but limited information is available on parental experiences of care for AI children in the ED. Our objective was to understand parental attitudes towards ED care for AI children. Focus groups were held with AI parents/caregivers at five sites in the Upper Midwest. Traditional content analysis was used to identify themes. A total of 70 parents participated in ten focus groups. Three main themes were identified: healthcare environment, access to care, and interaction with providers. Healthcare environment issues included availability of specialists, wait times, and child-friendly areas. Transportation and financial considerations were major topics in access to care. Issues in interaction with providers included discrimination, stereotyping, and trust. This is one of the first studies to assess parent perspectives on ED use for AI children. Obtaining parental perspectives on ED experiences is critical to improve patient care and provide important information for ED providers.
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Affiliation(s)
- Wyatt J Pickner
- Population Health, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA.,Department of Health Services, Community-Oriented Public Health Program, University of Washington School of Public Health, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA, 98195-7660, USA
| | - Katherine M Ziegler
- Population Health, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA.,Department of Epidemiology, Colorado School of Public Health at the University of Colorado at Denver, 13001 E. 17th Place, B119 Bldg 500, 3rd Floor West Wing, Aurora, CO, 80045, USA
| | - Jessica D Hanson
- Population Health, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA
| | - Nathaniel R Payne
- Quality Improvement, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN, 55404, USA
| | - Heather G Zook
- Quality Improvement, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN, 55404, USA.,Evaluation Division, Professional Data Analysts, Inc, 219 Main St. SE, Suite 302, Minneapolis, MN, 55414, USA
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN, 55404, USA
| | - Tess L Weber
- Population Health, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA
| | - Jaymi N Russo
- Population Health, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA
| | - Susan E Puumala
- Population Health, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA. .,Department of Pediatrics, University of South Dakota Sanford School of Medicine, 1400 W 22nd St, Sioux Falls, SD, 57105, USA.
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81
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Crilly J, Cameron CM, Scuffham PA, Good N, Scott R, Mihala G, Sweeny A, Keijzers G. Emergency department presentations in infants: Predictors from an Australian birth cohort. J Paediatr Child Health 2017; 53:981-987. [PMID: 28744935 DOI: 10.1111/jpc.13617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/10/2017] [Accepted: 04/10/2017] [Indexed: 12/01/2022]
Abstract
AIM Infants under 12 months of age are disproportionately represented amongst emergency department (ED) presentations, and infants are more likely to be frequent ED users. This study aimed to describe and identify psychosocial predictors of ED presentation in infants. METHODS A prospective birth cohort from Queensland and New South Wales (Environments for Healthy Living) was used to understand infant health service use. Baseline and 12-month questionnaire data pertaining to children born between 2006 and 2011 were used to identify predictors of ED presentation, using multiple regression analysis. RESULTS Of the 2184 children in the cohort with available baseline and 12-month data, 579 (27%) presented at least once to an ED during their first 12 months of life. Statistically significant predictors of ED presentation in the multivariate analysis included the mother having asthma (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.15-2.39) and a higher Kessler-6 score (a measure of psychological distress) of the primary carer at baseline (OR 1.04, 95% CI 1.01-1.08). Maternal education level was not associated with ED presentations of infants. CONCLUSIONS This study describes maternal and child factors of children who present to the ED in the first year of life. Factors related to an infant's support system were found to be predictors for an ED presentation in the first year of life. This study emphasises the need to review the maternal medical history and psychosocial situation. There may be benefits for health-care practitioners to take the opportunity (such as during routine childhood immunisation) to perform a brief screening tool (such as the Kessler-6) to understand psychological distress experienced by mothers. This may influence the likelihood of a child presenting to an ED within the first 12 months of life.
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Affiliation(s)
- Julia Crilly
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Cate M Cameron
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Paul A Scuffham
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Norm Good
- Australian e-Health Research Centre, CSIRO, Brisbane, Queensland, Australia
| | - Rani Scott
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Gabor Mihala
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Amy Sweeny
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia
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82
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Goto T, Hasegawa K, Faridi MK, Sullivan AF, Camargo CA. Emergency Department Utilization by Children in the USA, 2010-2011. West J Emerg Med 2017; 18:1042-1046. [PMID: 29085535 PMCID: PMC5654872 DOI: 10.5811/westjem.2017.7.33723] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/03/2017] [Accepted: 07/04/2017] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Epidemiological surveillance data for emergency department (ED) visits by children are imperative to guide resource allocation and to develop health policies that advance pediatric emergency care. However, there are sparse population-based data on patient-level information (e.g., the number of children who present to the emergency department [ED]). In this context, we aimed to investigate both the patient- and visit-level rates of ED utilization by children. METHODS This was a retrospective cohort study using population-based multipayer data - state ED databases (SEDD) and state inpatient databases (SID) - from six geographically-dispersed U.S. states (California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all children aged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visit rate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDD and SID data. We also repeated the analysis using the 2010 data to determine the consistency of the results across different years. RESULTS In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states. At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of these children, 25% presented to EDs 2-3 times per year with an approximately 1.5-fold variation across the states (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At the visit-level, 6.7 million ED visits were made by children in 2011 - 34 ED visits per 100 children annually. ED visits by children accounted for 22% of all ED visits (including both adults and children), with a relatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the 2010 data gave similar results for the ED utilization by children. CONCLUSION By using large population-based data, we found a substantial burden of ED visits at both patient- and visit-levels. These findings provide a strong foundation for policy makers and professional organizations to strengthen emergency care for children.
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Affiliation(s)
- Tadahiro Goto
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Kohei Hasegawa
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Mohammad Kamal Faridi
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Ashley F Sullivan
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A Camargo
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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83
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Peltz A, Samuels-Kalow ME, Rodean J, Hall M, Alpern ER, Aronson PL, Berry JG, Shaw KN, Morse RB, Freedman SB, Cohen E, Simon HK, Shah SS, Katsogridakis Y, Neuman MI. Characteristics of Children Enrolled in Medicaid With High-Frequency Emergency Department Use. Pediatrics 2017; 140:peds.2017-0962. [PMID: 28765381 PMCID: PMC5574719 DOI: 10.1542/peds.2017-0962] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years. METHODS Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use. RESULTS A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use. CONCLUSIONS One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.
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Affiliation(s)
- Alon Peltz
- Robert Wood Johnson Foundation Clinical Scholars Program and .,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | | | | | | | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Kathy N. Shaw
- Departments of Pediatrics and,Emergency Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rustin B. Morse
- Children’s Health System of Texas, and Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and,Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harold K. Simon
- Division of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia; and
| | - Samir S. Shah
- Divisions of Hospital Medicine and,Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark I. Neuman
- Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
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84
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Abstract
BACKGROUND American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. OBJECTIVE Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. RESEARCH DESIGN We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. RESULTS A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. CONCLUSIONS The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.
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85
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Samuels-Kalow ME, Rhodes KV, Henien M, Hardy E, Moore T, Wong F, Camargo CA, Rizzo CT, Mollen C. Development of a Patient-centered Outcome Measure for Emergency Department Asthma Patients. Acad Emerg Med 2017; 24:511-522. [PMID: 28146297 PMCID: PMC5426977 DOI: 10.1111/acem.13165] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/26/2016] [Accepted: 01/14/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize overtesting and overtreatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care. OBJECTIVE The objective was to identify concepts for inclusion in a patient-reported outcome measure for ED care and assess differences in potential concepts by health literacy. METHODS A three-phase qualitative study was completed using freelisting and semistructured interviewing for concept identification, member checking for concept ranking, and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2. RESULTS Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic/literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access, and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in five questions for the proposed measure. CONCLUSIONS A stepwise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The four key concepts identified for inclusion: symptom improvement, medication access, correct medication use, and asthma knowledge are not measured by existing quality metrics.
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Affiliation(s)
| | - Karin V Rhodes
- Office of Population Health, Hofstra Northwell School of Medicine, Great Neck, NY
| | - Mira Henien
- Drexel University College of Medicine, Philadelphia, PA
| | - Emily Hardy
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Thomas Moore
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Caroline T Rizzo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Cynthia Mollen
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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86
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Abstract
OBJECTIVES Emergency department (ED) crowding is associated with increased morbidity and mortality. Its etiology is multifactorial, and frequent ED use (defined as more or equal to five visits per year) is a major contributor to high patient volumes. Our primary objective is to characterize the frequent user population. Our secondary objective is to examine risk factors for frequent emergency use. METHODS We conducted a retrospective cohort study of pediatric emergency department (PED) visits at the Montreal Children's Hospital using the Système Informatique Urgence (SIURGE), electronic medical record database. We analysed the relation between patient's characteristics and the number of PED visits over a 1-year period following the index visit. RESULTS Patients totalling 52,088 accounted for 94,155 visits. Of those, 2,474 (4.7%) patients had five and more recurrent visits and accounted for 16.6% (15,612 visits) of the total PED visits. Lower level of acuity at index visit (odds ratio [OR] 0.85) was associated with a lower number of recurrent visits. Lower socioeconomic status (social deprivation index OR 1.09, material deprivation index OR 1.08) was associated with a higher number of recurrent visits. Asthma (OR 1.57); infectious ear, nose, and sinus disorders (OR 1.33); and other respiratory disorders (OR 1.56) were independently associated with a higher incidence of a recurrent visit within the year following the first visit. CONCLUSION Our study is the first Canadian study to assess risk factors of frequent pediatric emergency use. The identified risk factors and diagnoses highlight the need for future evidence-based, targeted innovative research evaluating strategies to minimize ED crowding, to improve health outcomes and to improve patient satisfaction.
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87
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Samuels-Kalow ME, Bryan MW, Shaw KN. Predicting Subsequent High-Frequency, Low-Acuity Utilization of the Pediatric Emergency Department. Acad Pediatr 2017; 17:256-260. [PMID: 27876588 DOI: 10.1016/j.acap.2016.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 11/11/2016] [Accepted: 11/12/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To derive and test a predictive model for high-frequency (4 or more visits per year), low-acuity (emergency severity index 4 or 5) utilization of the pediatric emergency department. METHODS The study sample used 3 years of data (2012-2014) from a single tertiary-care children's hospital for patients <21 years of age. Utilization in 2013 defined the index visit; prior utilization was drawn from 2012; and 2014 was used for outcome measurement. Candidate predictor variables were those that would be available at the time of triage. Data were split into derivation and test sets randomly; variables with a significant univariate association in the derivation set were included for multivariable modeling. The final model from the derivation set was then tested in the validation set, with calculation of a receiver operating characteristic curve. RESULTS There were 90,972 visits in 2013, of which 61,430 were first (index) visits. A total of 590 (1%) had 4 or more triage level 4 or 5 visits in the following year (2014). The final model included site of primary care, age, acuity, previous utilization, race, and insurance, and had an area under the receiver operating characteristic curve of 0.84. CONCLUSIONS Data available to the emergency department provider at the time of initial visit triage can predict utilization for low-acuity complaints in the subsequent year. Future work should focus on validation and refinement of the model in additional settings, and electronic calculation of risk status for targeted intervention to improve appropriate utilization of health care services.
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Affiliation(s)
| | - Matthew W Bryan
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Kathy N Shaw
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pa
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88
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Johnson LH, Beck AF, Kahn RS, Huang B, Ryan PH, Olano KK, Auger KA. Characteristics of Pediatric Emergency Revisits After an Asthma-Related Hospitalization. Ann Emerg Med 2017; 70:277-287. [PMID: 28302425 DOI: 10.1016/j.annemergmed.2017.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 12/15/2016] [Accepted: 01/10/2017] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We identify and characterize factors related to subsequent emergency revisits among children hospitalized for asthma. METHODS This population-based, prospective, observational cohort included children aged 2 to 16 years, hospitalized for asthma at an urban pediatric facility and followed for greater than or equal to 12 months. The primary outcome was asthma-related emergency revisit within 12 months of discharge. Revisits were identified by billing codes, respiratory chief complaints, and medications administered (eg, albuterol, systemic corticosteroids), dispensed, or prescribed. Predictors and covariates include demographic, socioeconomic, access, and environmental exposure variables collected during index admission. Multivariable logistic regression was used to evaluate the association between predictors and odds of asthma-related revisit. RESULTS A total of 671 children were enrolled; the majority were boys (65%), aged 4 to 11 years (59%), black (59%), and publicly insured (73%). There were 274 patients (41%) who were treated for asthma-related emergency revisits within 12 months of the index admission. In adjusted models, younger children, black children, children with excellent reported access to primary care, and children with a history of inhaled steroids were more likely to experience emergency revisits. Low income, detectable cotinine levels, and traffic exposure did not independently predict revisit. CONCLUSION Asthma-related emergency revisit is common after hospitalization, with more than 40% of children returning within 12 months. Socioeconomic and exposure-related risk factors typically predictive of asthma morbidity were not independently associated with emergency revisit among children in this cohort.
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Affiliation(s)
- Laurie H Johnson
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Andrew F Beck
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Robert S Kahn
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Patrick H Ryan
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kelly K Olano
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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89
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Berry JG, Rodean J, Hall M, Alpern ER, Aronson PL, Freedman SB, Brousseau DC, Shah SS, Simon HK, Cohen E, Marin JR, Morse RB, O’Neill M, Neuman MI. Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid. J Pediatr 2017; 182:267-274. [PMID: 27979584 PMCID: PMC7398048 DOI: 10.1016/j.jpeds.2016.11.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/17/2016] [Accepted: 11/16/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess the impact of chronic conditions on children's emergency department (ED) use. STUDY DESIGN Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the "highest" visit rates. RESULTS The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees). CONCLUSIONS The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.
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Affiliation(s)
- Jay G. Berry
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Matthew Hall
- Children’s Hospital Association, Overland Park, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital and Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - David C. Brousseau
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious, Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer R Marin
- Departments of Pediatrics and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rustin B. Morse
- Children’s Health System of Texas, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Margaret O’Neill
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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90
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Frequent users in paediatric emergency departments. Who are they? Why do they consult? ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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91
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Rivas García A, Manrique Martín G, Butragueño Laiseca L, Mesa García S, Campos Segura A, Fernández Iglesia V, Moreno Sánchez R, Aguilar Mulet JM. [Frequent users in paediatric emergency departments. Who are they? Why do they consult?]. An Pediatr (Barc) 2017; 86:67-75. [PMID: 27089983 DOI: 10.1016/j.anpedi.2016.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/08/2016] [Accepted: 03/07/2016] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine the prevalence of frequent Paediatric Emergency Departments users and to analyse their characteristics, comparing initial consultations and re-consultations. METHODS This is a multicentre retrospective cohort study of all patients who made 10 or more visits to the Paediatric Emergency Departments of 5 public hospitals between 1 January 2013 and 31 December 2013. An analysis was performed on the patient demographics and clinical data of the first consultation and consecutive re-consultations. RESULTS Frequent users represented 0.60% (95% CI: 0.56-0.64%) of Emergency Department users, and accounted for 3.93% (95% CI: 3.47-4.39%) of all visits. The most numerous age group consisted of children under 2 years old (66.6%). Frequent users distributed their visits throughout the year (62.3%; P<.001), and did not have a chronic condition associated with their chief complaint (86.4%; P<.001). They were usually classified as non-urgent or less urgent in triage (3,186 vs. 1,812; P<.001), and often did not require any intervention, such as complementary tests (79.4%) or observation/treatment (60%). Admission rate was similar to the general paediatric population (5.3%). Re-consultations represented 27% of these patient visits, mostly related to persistence of symptoms (56.3%), with 13.8% of them consulting their Primary Care physician before seeking successive medical attention in the Paediatric Emergency Department. CONCLUSIONS Paediatric frequent users often ask for medical care in the Emergency Department before consulting their Primary Care physician. They present with less urgent processes and do not systematically need diagnostic or therapeutic interventions. Re-consultations make up a significant number of visits, in which more interventions are done and more children are admitted.
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92
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Patel AD, Wood EG, Cohen DM. Reduced Emergency Department Utilization by Patients With Epilepsy Using QI Methodology. Pediatrics 2017; 139:peds.2015-2358. [PMID: 28108581 DOI: 10.1542/peds.2015-2358] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Epilepsy or seizure care is the most common neurologic condition that presents to an emergency department (ED) and accounts for a large number of annual cases. Our aim was to decrease seizure-related ED visits from our baseline of 17 ED visits per month per 1000 patients to 13.6 ED visits per month per 1000 patients (20%) by July 2014. METHODS Our strategy was to develop a quality improvement (QI) project utilizing the Institute for Healthcare Improvement model. Our defined outcome was to decrease ED utilization for children with epilepsy. Rate of ED visits as well as unplanned hospitalizations for epilepsy patients and associated health care costs were determined. A QI team was developed for this project. Plan do study act cycles were used with adjustments made when needed. RESULTS Nineteen months after implementation of the interventions, ED visits were reduced by 28% (from 17 visits per month per 1000 patients to 12.2 per month per 1000 patients) during the past year. The average number of inpatient hospitalizations per month was reduced by 43% from 7 admissions per month per 1000 patients to 4 admissions per month per 1000 patients. For both outcome measures, a 2-sample Poisson rate exact test yielded a P value < .0001. Health care claims paid were less with $115 200 reduction for ED visits and $1 951 137 reduction for hospitalizations. CONCLUSIONS Applying QI methodology was highly effective in reducing ED utilization and unplanned hospitalizations for children with epilepsy at a free-standing children's hospital.
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Affiliation(s)
- Anup D Patel
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and .,Divisions of Neurology and
| | - Eric G Wood
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Daniel M Cohen
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and.,Emergency Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
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93
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Zonfrillo MR, Macy ML, Cook LJ, Funai T, Stanley RM, Chamberlain JM, Cunningham RM, Alpern ER. Anticipated resource utilization for injury versus non-injury pediatric visits to emergency departments. Inj Epidemiol 2016; 3:12. [PMID: 27231667 PMCID: PMC4853460 DOI: 10.1186/s40621-016-0077-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/05/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Childhood injuries are increasingly treated in emergency departments (EDs) but the relationship between injury severity and ED resource utilization has not been evaluated. The objective of this study was to compare resource utilization for pediatric injury-related ED visits across injury-severity levels and with non-injury visits, using standardized, validated scales. METHODS A retrospective analysis of 2004-2008 ED visits from the Pediatric Emergency Care Applied Research Network Core Data Project. Maximum Abbreviated Injury Scale severity (MAIS) and Severity Classification System (SCS) scores were calculated and compared. MAIS and SCS are ordinal scales from 1 (minor injury) to 6, and 1 (low anticipated resource utilization) to 5, respectively. ED length of stay (LOS) and admission percentages were calculated as comparative proxy measures of resource utilization. RESULTS There were 763,733 injury visits and 2,328,916 non-injury visits, most with SCS of 2 or 3. Of the injured patients, 59.2 % had an MAIS of 1. ED LOS and admission percentage increased with increasing MAIS from 1-5. LOS and admission percentage increased with increasing SCS in both samples. Median LOS was shorter for injured versus non-injured patients with SCS 3-5. Non-injured patients with SCS 2-5 were more likely admitted than injured patients. Most injured patients had an SCS 3 with an MAIS 1-2, or an SCS 2 with an MAIS 1, with no correlation between the two scales. CONCLUSION While admission rates and LOS increase with increasing AIS and SCS severity, these two classification schemas do not reliably correlate. Similarly, ED visit metrics differ between injured and non-injured patients in similar SCS categories. Although AIS and SCS both have value, these differences should be considered when using these schemas in research and quality improvement.
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Affiliation(s)
- Mark R. Zonfrillo
- Department of Emergency Medicine, Alpert Medical School of Brown University, 55 Claverick Street, 2nd Floor, Providence, RI 02903 USA
- Injury Prevention Center, Hasbro Children’s Hospital, Providence, RI USA
| | - Michelle L. Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI USA
- University of Michigan Injury Center, Ann Arbor, MI USA
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, MI USA
| | - Lawrence J. Cook
- Department of Pediatrics, University of Utah, Salt Lake City, UT USA
| | - Tomohiko Funai
- Department of Pediatrics, University of Utah, Salt Lake City, UT USA
| | - Rachel M. Stanley
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH USA
| | - James M. Chamberlain
- Department of Pediatrics & Emergency Medicine, Children’s National Health System, George Washington University, Washington, DC, USA
| | - Rebecca M. Cunningham
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI USA
- University of Michigan Injury Center, Ann Arbor, MI USA
| | - Elizabeth R. Alpern
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - For the Pediatric Emergency Care Applied Research Network (PECARN)
- Department of Emergency Medicine, Alpert Medical School of Brown University, 55 Claverick Street, 2nd Floor, Providence, RI 02903 USA
- Injury Prevention Center, Hasbro Children’s Hospital, Providence, RI USA
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI USA
- University of Michigan Injury Center, Ann Arbor, MI USA
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, MI USA
- Department of Pediatrics, University of Utah, Salt Lake City, UT USA
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH USA
- Department of Pediatrics & Emergency Medicine, Children’s National Health System, George Washington University, Washington, DC, USA
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
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94
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Mudd SS, Ogborn CJ, Bollinger ME, Morphew T, Kub J, Lewis-Land C, Bellin MH, Butz A. Parental decision making associated with pediatric emergency department use for asthma. Ann Allergy Asthma Immunol 2016; 117:490-494. [PMID: 27788877 PMCID: PMC5117360 DOI: 10.1016/j.anai.2016.08.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/16/2016] [Accepted: 08/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Disadvantaged minority children are disproportionately affected by asthma. This group is also known to frequently use the emergency department (ED) for asthma care. Understanding decisions for use of the ED is important to prevent high cost. OBJECTIVE To examine caregiver factors associated with the decision to use the ED for asthma care in inner-city children with asthma. METHODS One hundred fifty participants in a randomized clinical trial testing the effectiveness of a home-based asthma intervention were enrolled, and questionnaires were administered to caregivers during the child's ED asthma visit. Sociodemographics, health characteristic data, and caregiver interview data were examined to ascertain factors that affected caregiver decision making to use the ED for asthma care. A cluster analysis was performed to correlate caregiver reasons for the decision to use the ED for asthma care. RESULTS Three clusters emerged for decision making: urgency, preference for the use of the ED, and access to care issues. The perception of urgency was the most common reason reported by caregivers (91%) followed by reporting a preference for the ED for care (37%) and reporting access to care issues (31%). Access to care was primarily attributable to the inability to get a same-day appointment with their primary care practitioner (24%). CONCLUSION The caregiver factors involved in the decision to use the ED can provide a basis for further intervention and investigation. Such factors include caregiver asthma home management, improvement in relationships with primary care practitioners, and access to care-related issues.
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Affiliation(s)
- Shawna S Mudd
- Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, Maryland.
| | - C Jean Ogborn
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Joan Kub
- Department of Community and Public Health, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Cassie Lewis-Land
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa H Bellin
- University of Maryland School of Social Work, Baltimore, Maryland
| | - Arlene Butz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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95
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Kersten EE, LeWinn KZ, Gottlieb L, Jutte DP, Adler NE. San Francisco children living in redeveloped public housing used acute services less than children in older public housing. Health Aff (Millwood) 2016; 33:2230-7. [PMID: 25489043 DOI: 10.1377/hlthaff.2014.1021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Understanding the links between housing and health is increasingly important. Poor housing quality is a predictor of poor health and developmental problems in low-income children. We examined associations between public housing type and recurrent pediatric emergency and urgent care hospital visits. Children ages 0-18 with public insurance who sought emergency care from any of three large medical systems in San Francisco were categorized by whether they lived in public housing redeveloped through the federal HOPE VI program, nonredeveloped public housing, or nonpublic housing in a census tract that also contained public housing. After we adjusted for potential confounding characteristics, we found that children living in nonredeveloped public housing were 39 percent more likely to have one or more repeat visits within one year for acute health care services unrelated to the initial visit, compared to children who lived in redeveloped HOPE VI housing. We observed no differences in repeat visits between children in redeveloped HOPE VI housing and those in nonpublic housing. These findings support the continued redevelopment of public housing as a means of both improving the health of vulnerable high-risk children from low-income neighborhoods and reducing health care costs.
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Affiliation(s)
- Ellen E Kersten
- Ellen E. Kersten is a PhD candidate in environmental science, policy, and management at the University of California, Berkeley
| | - Kaja Z LeWinn
- Kaja Z. LeWinn is an assistant professor of psychiatry at the University of California, San Francisco
| | - Laura Gottlieb
- Laura Gottlieb is an assistant professor of family and community medicine at the University of California, San Francisco
| | - Douglas P Jutte
- Douglas P. Jutte is an associate professor at the School of Public Health, University of California, Berkeley, and executive director of the Build Healthy Places Network, in San Francisco
| | - Nancy E Adler
- Nancy E. Adler is a professor of psychiatry and pediatrics and director of the Center for Health and Community at the University of California, San Francisco
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96
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Simon EL, Kovacs M, Hayslip D, Jouriles N. Characterizing Children Presenting to Three Freestanding EDs. Am J Emerg Med 2016; 34:2045-2048. [DOI: 10.1016/j.ajem.2016.07.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 07/27/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022] Open
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Christensen EW, Kharbanda AB, Velden HV, Payne NR. Predicting Frequent Emergency Department Use by Pediatric Medicaid Patients. Popul Health Manag 2016; 20:208-215. [PMID: 27564725 DOI: 10.1089/pop.2016.0051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective of this study was to determine the patient characteristics and health care utilization patterns that predict frequent emergency department (ED) use (≥4 visits per year) over time to assist health care organizations in targeting patients for care management. This was a retrospective, population-based study of 13,265 Medicaid children aged 0-20 years who were attributed to a single pediatric accountable care organization for at least 2 consecutive years between June 2012 and May 2015. Year-to-year persistence as a frequent ED user was 36.3% (95% confidence interval [CI]: 33.4 to 38.4), which does not support the notion that once a frequent user, always a frequent user. Hence, interventions to reduce frequent ED use may appear to be effective when ED use would have regressed toward the mean without any intervention. At an individual patient level, predictability of frequent ED use was 0.437 (95% CI: 0.358 to 0.485) across frequent ED users of all ages compared with 0.723 (95% CI: 0.435 to 0.824) for those aged <1 year. Accordingly, this latter group may be a better target for interventions than frequent ED users generally.
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Affiliation(s)
- Eric W Christensen
- 1 Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
| | - Anupam B Kharbanda
- 2 Department of Critical Care and Emergency Medicine, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
| | - Heidi Vander Velden
- 1 Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
| | - Nathaniel R Payne
- 1 Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
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98
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Johnson LH, Chambers P, Dexheimer JW. Asthma-related emergency department use: current perspectives. Open Access Emerg Med 2016; 8:47-55. [PMID: 27471415 PMCID: PMC4950546 DOI: 10.2147/oaem.s69973] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Asthma is one of the most common chronic pediatric diseases. Patients with asthma often present to the emergency department for treatment for acute exacerbations. These patients may not have a primary care physician or primary care home, and thus are seeking care in the emergency department. Asthma care in the emergency department is multifaceted to treat asthma patients appropriately and provide quality care. National and international guidelines exist to help drive clinical care. Electronic and paper-based tools exist for both physicians and patients to help improve emergency, home, and preventive care. Treatment of patients with asthma should include the acute exacerbation, long-term management of controller medications, and controlling triggers in the home environment. We will address the current state of asthma research in emergency medicine in the US, and discuss some of the resources being used to help provide a medical home and improve care for patients who suffer from acute asthma exacerbations.
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Affiliation(s)
| | | | - Judith W Dexheimer
- Division of Emergency Medicine; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Arbogast KB, Curry AE, Pfeiffer MR, Zonfrillo MR, Haarbauer-Krupa J, Breiding MJ, Coronado VG, Master CL. Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network. JAMA Pediatr 2016; 170:e160294. [PMID: 27244368 PMCID: PMC6025897 DOI: 10.1001/jamapediatrics.2016.0294] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained. OBJECTIVE To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury. DESIGN, SETTING, AND PARTICIPANTS In this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Children's Hospital of Philadelphia's (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected. MAIN OUTCOMES AND MEASURES Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion. RESULTS A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay patients [24%]). CONCLUSIONS AND RELEVANCE The findings suggest estimates of concussion incidence based solely on ED visits underestimate the burden of injury, highlight the importance of the primary care setting in concussion care management, and demonstrate the potential for EHR systems to advance research in this area.
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Affiliation(s)
- Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania2University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Allison E. Curry
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa R. Pfeiffer
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark R. Zonfrillo
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania2University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Juliet Haarbauer-Krupa
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew J. Breiding
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Victor G. Coronado
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christina L. Master
- University of Pennsylvania Perelman School of Medicine, Philadelphia4Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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100
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Baltrus P, Xu J, Immergluck L, Gaglioti A, Adesokan A, Rust G. Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach. J Asthma 2016; 54:53-61. [PMID: 27285734 DOI: 10.1080/02770903.2016.1196367] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. RESULTS The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. CONCLUSIONS At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.
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Affiliation(s)
- Peter Baltrus
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,b Department of Community Health & Preventive Medicine , Morehouse School of Medicine , Atlanta , GA , USA
| | - Junjun Xu
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA
| | - Lilly Immergluck
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,c Departments of Microbiology , Biochemistry, & Immunology and Pediatrics, Morehouse School of Medicine , Atlanta , GA , USA
| | - Anne Gaglioti
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,d Department of Family Medicine , Morehouse School of Medicine , Atlanta , GA , USA
| | - Adeola Adesokan
- e Master of Science in Clinical Research Program, Morehouse School of Medicine , Atlanta , GA , USA
| | - George Rust
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,d Department of Family Medicine , Morehouse School of Medicine , Atlanta , GA , USA
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