Emergency department utilization by adolescents in the United States

Children's health insurance status and emergency department utilization in the United States

OBJECTIVES

Emergency department (ED) overcrowding has become a national problem. Children account for nearly 25% of overall ED visits. It has been reported that uninsured and publicly insured children are likely to visit the ED for urgent and nonurgent problems, yet it remains unclear to what extent health insurance status would influence children's overall ED utilization or ED utilization for nonurgent problems at the national level after controlling for other confounding factors. The objective of this study was to examine the effect of health insurance status on children's overall ED utilization and children's ED utilization for nonurgent problems among the general pediatric population in the United States.

METHODS

Secondary analysis of the household component of the 1997 Medical Expenditure Panel Survey on 10 193 children younger than 18 years. The main outcome measures were annual overall ED utilization and ED utilization for nonurgent problems.

RESULTS

During 1997, 10.8% of children were uninsured for the entire year. A total of 17.5% of children were publicly insured the entire year, whereas 55.3% of children held private insurance the entire year. There were also 16.5% of children who were insured only part of the year. Without adjusting for covariates, publicly insured children were more likely to have an ED visit during the year than both privately insured children (unadjusted odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.03-1.55) and uninsured children (unadjusted OR: 1.46; 95% CI: 1.1-1.95). The difference between publicly insured and privately insured children (adjusted OR: 0.90; 95% CI: 0.70-1.16) and between publicly insured and uninsured children (adjusted OR: 1.12; 95% CI: 0.84-1.49) became insignificant after controlling for covariates. With or without adjustments for covariates, there was no significant difference in the likelihood of having an ED visit between privately insured and uninsured children. Similar to the utilization pattern of overall ED visits, publicly insured children were more likely to have a nonurgent ED visit than both privately insured (unadjusted OR: 1.86; 95% CI: 1.36-2.53) and uninsured children (unadjusted OR: 1.81; 95% CI: 1.15-2.84). Both differences disappeared after controlling for covariates. There was no significant difference in the likelihood of nonurgent ED visits between privately insured and uninsured children with or without adjustments for covariates.

CONCLUSIONS

Health insurance status was not associated with children's overall ED use or children's ED use for nonurgent problems at the national level. Our findings suggest that policy efforts in an attempt to relieve ED overcrowding conditions should look for measures beyond solely making changes in health insurance coverage for children.

Urinary tract infection and Chlamydia infection in adolescent females

STUDY OBJECTIVE

To examine whether clinical or laboratory findings could distinguish Chlamydia trachomatis (CT) from urinary tract infection (UTI) among adolescent females in whom providers tested for both.

DESIGN, SETTING, PARTICIPANTS

A laboratory database at an urban teen health center was reviewed to identify females who had both urine culture and ligase chain reaction (LCR) test for CT ordered at the same visit. History and physical findings were abstracted from the medical record. There were 81 visits with retrievable laboratory results and chart documentation.

MAIN OUTCOME MEASURES

UTI was defined as >1000 colony-forming units on culture, and CT was defined as positive LCR test. Pearson's Chi-squared test was used to assess strength of the hypothesized associations.

RESULTS

UTI was diagnosed in 20 (24%) and CT in 18 (22%) of 82 visits. Concurrent CT was diagnosed in 6 of 20 subjects with UTI. Symptoms and physical signs did not differentiate UTI from CT. Positive urinary nitrites were associated with UTI, but did not exclude CT. Similarly, wet prep evidence of trichomonas or white blood cells was associated with CT, but did not exclude UTI. Clinical diagnosis of CT or UTI was 50% sensitive and 70% specific.

CONCLUSIONS

Adolescent females who are screened for both CT and UTI have high rates of concurrent disease. Urinary or vaginal symptoms do not differentiate well between these infections. Clinical diagnosis is imprecise, suggesting that adolescent females with vaginal or urinary symptoms should be tested for both CT and UTI.

Adolescent health care expenditures: a descriptive profile

PURPOSE

To examine health care spending patterns for U.S. adolescents aged 10 to 18 years using nationally representative household survey data.

METHODS

We analyzed data from the 1997 Medical Expenditure Panel Survey on total expenditures and out-of-pocket expenditures for health care based on a sample of 4882 adolescents.

RESULTS

Compared with that for adults, health care expenditures for adolescents were low, averaging $799 US dollars per adolescent in 1997. Disabled and functionally impaired adolescents had disproportionately high expenditures ($1960 US dollars per capita). Blacks and adolescents living in poor families had disproportionately low expenditures ($358 and $609 US dollars per capita, respectively). Professional services provided by physicians and dentists accounted for more than one-half of all health care spending for adolescents. Only 2% of adolescents were hospitalized in 1997, but they accounted for about one-fifth of all health care expenditures. The share of health expenditures paid out of pocket varied by type of service, ranging from 3% for inpatient hospital care to 51% for dental care. When covered, insurance provided substantial financial protection for families of adolescents: those with public coverage paid 8%, those with private coverage paid 32%, and those without coverage paid 61% of their health care bills out of pocket. The share of health care bills paid out of pocket would be much lower if dental care was excluded.

CONCLUSIONS

On the basis of our findings that health care expenditures for adolescents are low and that insurance coverage provides critically needed financial protection, we conclude that further expansions of public and private health insurance coverage for this population would provide significant benefits at modest additional cost. Additional efforts to improve coverage of services that are not now well-covered, such as dental care, would also be valuable.

Psychosocial needs of young persons who are victims of interpersonal violence

OBJECTIVE

Although most emergency departments (EDs) in the United States treat a large number of patients who are victims of interpersonal violence, few address their psychosocial needs. We conducted this study to determine the needs of victims of interpersonal violence using a psychosocial assessment tool administered in the ED.

METHODS

We conducted a descriptive study of a prospective, consecutive random sample of young victims of violence in an inner city, level I adult and pediatric ED with 44,000 annual visits. Youths aged 10 to 24 years who were victims of life- or limb-threatening interpersonal violence in 1998 and 1999, excluding domestic violence, sexual assault, and child abuse, were interviewed using an assessment tool designed to determine the psychosocial needs of young persons. The youth assessment tool was composed of 13 constructs, including exposure to violence, legal issues, drug use and abuse, mental health problems, gang issues, gun accessibility, educational needs, employment, life skills, pregnancy and parenting issues, medical care, and recreational activities. The study was approved by our Institutional Review Board.

RESULTS

We interviewed 112 victims of interpersonal violence with a mean age of 18.6 years; 83.9% were male, 67.9% were African American, and 30.4% were Hispanic. Of the youths interviewed, 72.1% had been shot, 15.3% had been stabbed, and 12.9% had been assaulted. In addition, 66.3% had been involved with the law, 73.7% used alcohol, and 65.3% used illegal drugs. Of the interviewees, 41.2% answered yes to at least one question in the CAGE (cut down on your drinking? annoyed by criticism of your drinking? Guilty feeling about your drinking? ye-opener drinking?) assessment, 42.0% reported feeling sad or "down" prior to their injury, and half (54.1%) were involved in a gang. A total of 63.4% of the victims were not in school, did not finish school, or had not obtained a graduate equivalency diploma. The top psychosocial needs were determined to be educational issues (21.8%), occupational issues (ie, job; 16.8%), social issues (eg, gang involvement; 14.9%), and mental health problems (13.2%).

CONCLUSIONS

Young persons who are victims of interpersonal violence have a significant need for educational support, employment assistance, mental health services, and gang intervention services.

ED utilization: the effect of changing demographics from 1992 to 2000

To explore factors contributing to increased emergency department (ED) utilization, this retrospective chart review compared ED visits for a 2-week period in both 1992 and 2000 at a rural, tertiary medical center. Total ED visits increased 455 between the periods (% increase = 28.6%), whereas county population increased 18,253 (% increase = 16.1%) (P < 0.005). Average age increased from 35.2 +/- 23.8 years to 40.1 +/- 23.6 years (95% confidence interval, difference of means, 3.34 to 6.45). Patients over 80 years increased by 83%, whereas those over 90 years increased 138%. The admission rate, increased from 21.9% to 25.6% (P < 0.005). Patients with Medicare as primary insurance increased from 17.9% to 23.6% (P < 0.005). Increased age of the population, increased acuity as shown by 4 different measurements, and limited access to primary care physicians all contributed to increased ED demand in this study.

Important health provider characteristics: the perspective of urban ninth graders

Clinicians caring for adolescents may be better positioned to provide health care when equipped with an understanding of adolescents' preferences regarding provider characteristics. The purpose of this study is to obtain a manageable framework of adolescents' concerns about health care providers. A series of qualitative and quantitative data-collection methods were used to elicit and organize ideas about health care providers from ninth-grade students in Philadelphia. A 5-point Likert survey, based on ideas generated and prioritized in earlier qualitative stages, was administered in school. Exploratory and confirmatory factor analysis was used to uncover latent factors. A total of 2602 students returned usable surveys. A confirmatory factor analysis model including four latent factors (patient's interpersonal relationship with provider, concern for physical safety, concern for emotional safety, and provider counseling ability) explained 51.6% of the model variability. Urban ninth graders want providers with whom they can develop strong relationships, feel emotionally and physically safe, and turn to for counseling. Communication with adolescent-aged patients should be a standard component of health care training and should promote provider sensitivity to adolescent fears and needs in the health care setting.

Male adolescent use of health care services: where are the boys?

PURPOSE

To describe patterns of health care use by adolescent males in the United States and clinical practice characteristics associated with their use of adolescent-specific programs.

METHODS

Secondary analysis of three national data sets to determine health care use by male adolescents: the National Ambulatory Medical Care Survey [NAMCS (1994): pediatric, family physician, internal medicine, and obstetric/gynecologic outpatient visits]; National Hospital Ambulatory Medical Care Survey [NHAMCS (1994): outpatient department (OPD) and emergency department (ED) visits]; and Comprehensive Adolescent Health Services Survey [CAHSS (1995)]. Both NAMCS and NHAMCS are representative national probability samples. Total visit estimates by adolescents in 1994 to NAMCS sites were 387,076,630, to OPD sites were 6,511,244, and to ED sites were 13,161,824. For CAHSS, 468 programs (60% of eligible) participated. Data analyses were performed using two-tailed Student's t-tests and correlation testing.

RESULTS

Older male adolescents, aged 16-20 years, account for a lower percentage of total visits to NAMCS sites combined compared to younger males, aged 11-15 years (15.8% vs. 25.1%, p <.001), mainly owing to a significant decline in visits to pediatricians (3.2% vs. 14.9%, p <.001), despite significant increases in female health care use during the same time period. Younger males were seen at similar rates compared to females at NAMCS, NHAMCS-OPD and NHAMCS-ED sites, but older males account for a significantly lower percentage of total visits than females to all NAMCS sites combined (15.8% vs. 34.7%, p <.001), the NHAMCS-ED (26.4% vs. 31.5%, p <.05), and the NHAMCS-OPD (15.0% vs. 41.2%, p =.001). Among specialized adolescent sites (CAHSS), 13-19-year-old males account for fewer visits than females to all programs types: schools (40% vs. 60%), hospitals (33% vs. 67%), and community/health departments (25% vs. 75%) (all p's < or =.001). Clinical practice characteristics correlated with having a greater proportion of male adolescent visit varied depending on the types of adolescent program examined.

CONCLUSIONS

Younger male adolescents make health care visits in relatively equal proportions to females at all NAMCS and NHAMCS locations and visits by older males are significantly reduced. Male adolescent visits are lower than females at all adolescent-specific programs; school-based clinics see the highest proportion of males. Greater understanding of male adolescents' transition between providers from adolescence to adulthood is needed to improve care to male adolescents who under-use health services.

Access to care: a review of the emergency medicine literature

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.

[Adolescents at the Lenval's children's hospital emergency unit in Nice in 1999]

OBJECTIVE

The goal of this survey was to investigate adolescents' health through their utilization of a pediatric emergency unit.

METHODS

Prospective survey performed one week of each month in 1999 concerning the adolescents' (12 to 18 years) visits to the Lenval's children emergency care unit in Nice.

RESULTS

During the study period, 1,096 adolescents were examinated and accounting for 18.6% of the children admitted in the year. The main reasons for visits were injury-related visits (55.5%), non-accidental somatic complaints (38.7%), psychiatric disorders (5.5%), and psychosocial problems (0.4%). Most adolescent visits (68.6%) were not severe emergencies requiring hospital technical equipment support; about one-third of the visits (28.6%) were non urgent consultations; severe emergencies were fewer than 1%; there was no death. Compared with the other pediatrics age groups, adolescents more often used the hospital technical equipment (65.1% vs 45.4%), required a longer visit (62 +/- 33 vs 57 +/- 37 min), and had a higher hospitalization rate (13.4% vs 10.1%).

CONCLUSIONS

Adolescent emergency care requires multidisciplinary skills, such as traumatologic, gynecologic, psychiatric, and psychosocial compentence. Two units, absent at Lenval at the time of this survey, seem to be important for good care: space for very short hospitalization in the emergency unit and an adolescent-specific unit in the pediatric ward.

Patterns of ambulatory care use for gynecologic conditions: A national study

OBJECTIVE

This study was undertaken to describe the site of ambulatory care visits for gynecologic conditions in the United States and to identify patient factors associated with the site of care for these conditions.

STUDY DESIGN

We conducted a national cross-sectional study using data from the 1995-1996 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys. Visits to private physician offices, hospital outpatient departments, and emergency departments were selected if the principal diagnoses were consistent with 1 of 9 gynecologic categories. Multiple logistic regression was used for all diagnoses to identify factors associated with visits to emergency departments or hospital-based outpatient departments compared with factors associated with visits to private physician offices. Separate regression models were developed for individual diagnoses to test the hypothesis that the factors associated with the site of care would vary across different gynecologic conditions.

RESULTS

There were 23,194,000 visits for gynecologic conditions during the 2-year study period. Genital dysplasia, ovarian disorders, and uterine disorders were associated with greater use of hospital outpatient departments and emergency departments compared with physician offices. There was a 30% to 50% reduction in emergency room use for visits by women aged 45 years and older compared with visits by women aged 18 to 29 years. Emergency department use for several gynecologic conditions was 5 to 8 times greater for visits by women with household income <$29,000 than for visits by women with household income > or =$40,000.

CONCLUSION

Specific gynecologic diagnoses and patient factors are associated with greater use of emergency departments or hospital outpatient departments compared with physician offices. The association of these factors with the site of care varies across different gynecologic conditions.

Urban emergency department utilization by adolescents

This study describes urban emergency department (ED) utilization and follow-up referral patterns among adolescents. ED visits for 14-19-year-old patients at an urban university hospital with adjacent adult and pediatric emergency departments during specified months in 1993 were retrospectively reviewed. A subgroup (n=150) was randomly selected for detailed chart review. One thousand six hundred and thirty-six adolescents were seen in the ED during the study period. Public assistance (n=763; 47%) and commercial insurance (n=480; 29%) were the most common forms of insurance, followed by self-pay (n=357; 22%). The majority of triage codes for ED visits were nonurgent (n=140; 93%). Twenty-five patients (17%) were not referred for follow-up upon ED discharge. Adolescents on public assistance or without insurance may frequently utilize an urban ED for nonurgent medical problems. A group of patients did not identify a primary care provider at triage and were not referred for follow-up. Defining medical problems for which adolescents utilize the ED may help health professionals to tailor community resources to better serve adolescent health care needs.

Opportunistic urine ligase chain reaction screening for sexually transmitted diseases in adolescents seeking care in an urban emergency department

STUDY OBJECTIVE

Neisseria gonorrhoeae and Chlamydia trachomatis are the most common bacterial sexually transmitted diseases (STDs) in sexually active youth and many infections are asymptomatic or unrecognized. This study used ligase chain reaction assays for determination of prevalence of gonococcal and chlamydial infections in adolescents seeking care at an urban emergency department.

METHODS

An unlinked prevalence study was performed with ligase chain reaction tests on voided urine specimens from a convenience sample of adolescents 14 years or older who sought care at the Children's Hospital of Alabama ED. Demographic data and data on care provided in the ED were determined from retrospective chart review of those patients whose urine specimens were tested.

RESULTS

Of 282 urine specimens screened, 13.5% (38) yielded positive findings on ligase chain reaction testing for either or both pathogens (20 [7%] positive for N gonorrhoeae, 23 [8%] positive for C trachomatis). In the context of acute care, gonorrhea or chlamydial infection was diagnosed in 5 (1.8%). STD prevalence did not vary significantly by age. Only 39% (15/38) of patients with infections detected by ligase chain reaction testing received potentially effective antibiotics as a result of their urgent care evaluation.

CONCLUSION

Many adolescents use the ED for nonurgent care and unsuspected STDs are often missed. Urine ligase chain reaction testing is a sensitive, noninvasive means of detecting STDs by which unsuspected adolescent STD cases can be detected in an ED setting.

Trends in emergency department utilization, 1988-1997

OBJECTIVES

To study changes in ED utilization over a ten-year period; and to try to identify factors that affect utilization.

METHODS

This study was conducted in a university-affiliated rural tertiary referral center in a stage 1 managed care market, providing primary emergency services to a county of 120,000 and tertiary services to a 29-county area with 1.2 million people. The year of visit, time of visit, level of care required, length of stay (LOS), and admission status were entered into a computer database for each ED visit.

RESULTS

Over the period from 1988 to 1997, the population grew by 18.7%. Over the same time period, the number of ED visits grew 27%. By regression analysis, the number of ED visits was directly related to the size of the service population (correlation coefficient 0.97). During the study period, patient acuity increased, with urgent visits increasing from 45% to 52% while nonurgent visits declined from 55% to 48%. Percentage of patients admitted increased from 14% in 1989 to 20% in 1997. Percentage of patients with LOS exceeding six hours also increased, from 8% in 1989 to 16% in 1997.

CONCLUSIONS

For the study hospital there was a direct relationship between the ED utilization and population size as well as a historical trend toward increased patient acuity. These trends quantified at one hospital may reflect trends occurring throughout the United States that would affect ED staffing, space, and resource needs.

Can sick children tell time?: emergency department presentation patterns of critically ill children

OBJECTIVE

Children show a consistent pattern of ED use, with the majority of patients presenting during the late afternoon and evening hours. This study evaluated whether such a diurnal pattern also exists for critically ill children and the implications of such a presentation pattern on ED staffing.

METHODS

A review was performed of the ED diagnoses and times of presentation for children less than 12 years of age at 28 nonpediatric hospitals over the six-year period from July 1990 to October 1996. In addition to total ED pediatric visits, a subset of critically ill children (CIC) were identified as those with an ED diagnosis of: meningitis, cardiac arrest, diabetic ketoacidosis, status epilepticus, meningococcemia, or epiglottitis, or those undergoing endotracheal intubation in the ED. A second group of non-critically ill children (NCIC) was composed of children with an ED diagnosis of otitis media, tonsillitis, or pharyngitis. Data collected on each patient included age, diagnosis, site of care, and time of service. Presentation patterns for all three groups were compared for time of day, with statistical analysis through chi-square, ANOVA, and Spearman's rho correlation.

RESULTS

A total of 409,820 pediatric ED visits were examined, with 688 CIC children and 28,344 NCIC identified. Presentation patterns for NCIC visits mirrored those of the total pediatric population, with the traditional increase in the late afternoon and evening hours (correlation 0.96). CIC presented much more erratically, with a distribution spread more uniformly throughout the day compared with the total pediatric population (correlation 0.72). Thirty-seven percent of CIC presented during the evening hours of 16:00 to 24:00, compared with 49% for NCIC and 53% for the total pediatric population, while 22% of CIC presented from 24:00 to 08:00 compared with only 13% of NCIC and 10% of total pediatric patients (p < 0.001).

CONCLUSION

Critically ill children present more uniformly throughout the day and do not have the same presentation patterns as ambulatory children. ED staffing should reflect this difference and not focus pediatric ED services simply on hours of peak pediatric visits.

The LUNAR project: A description of the population of individuals who seek health care at emergency departments

INTRODUCTION

Although little information exists about the consumers of emergency services and their illness behaviors, such information is essential for decision making by providers, administrators, and policy makers. The purpose of the LUNAR Project was to describe the population of individuals who seek health care at emergency departments.

METHODS

After they attended a training course, 90 emergency nurses served as site coordinators in 89 emergency departments in 35 states. A standardized protocol was used to collect data retrospectively from 140 randomly selected patient records at each site. The final sample included 12,422 ED patients.

RESULTS

Overall, 52% of the patient visits were for nonurgent care, 40% were for urgent care, and 8% were for emergent care. Most visits occurred between 10 AM and 8 PM and peaked at 6 PM. Children and younger adults were the largest consumers of services, primarily for nonurgent care. The most frequent reasons for visits were fever, chest pain, and abdominal pain, and the most common discharge diagnoses were middle ear infection, chest pain, and acute upper respiratory infection.

DISCUSSION

The profile of ED patients showed a need for new types of services to provide nonurgent care and new interventions for preventing illnesses and injuries commonly treated in the emergency department.

Utilization of physician offices by adolescents in the United States

Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years.

OBJECTIVE

To explore the utilization of physician offices in the United States by early (11-14 years), middle (15-17 years), and late (18-21 years) adolescents.

DESIGN

Secondary analysis of the 1994 National Ambulatory Medical Care Survey, focusing on visits made by the three adolescent age groups.

SETTING

Nationally representative sample of 2426 physicians in nonfederal, nonhospital offices.

SUBJECTS

A total of 33 598 visits by patients of all ages, representing 681.5 million visits in 1994.

MAIN OUTCOME MEASURES

Number of visits, health insurance, providers seen, duration of visits, reasons for visits, resulting diagnoses, and counseling provided.

RESULTS

Adolescents aged 11 to 21 years made 9.1% (61.8 million) of the total office visits and represented 15.4% of the total US population in 1994. This underrepresentation in visits held across all three adolescent age subgroups. Within the adolescent cohort, whites were overrepresented relative to their population proportion (78.5% of visits, 67.6% of population) and blacks and Hispanic adolescents were underrepresented (8.3% and 9.3% of visits, 15.5% and 13.1% of population). Middle adolescence signaled a life turning point from male to female predominance in office visits. Peak lifetime uninsurance rates occurred at middle adolescence for females (18.7%) and late adolescence for males (24.0%). Between childhood and early adolescence, public insurance decreased from 24.7% to 15.7% and uninsurance increased from 12.7% to 19.7%. Pediatricians accounted for the highest proportion of early adolescent visits (41.2%), family physicians for middle adolescent visits (35.3%), obstetrician-gynecologists for late adolescent female visits (37.3%), and family physicians for late adolescent male visits (34.8%). Mean visit duration during adolescence was 16 minutes, did not differ by age subgroup or sex, exceeded that of children (14.6 minutes), and was shorter than that of adults (19.3 minutes). Obstetrician-gynecologists spent more time with adolescents than did other physicians. Education or counseling was included in 50.4% of adolescent visits, ranging from 65.1% for obstetrician-gynecologists to 34.8% for internists. During early adolescence, the leading reasons for both male and female visits were respiratory (19.4%), dermatological (10.0%), and musculoskeletal (9.7%). A similar profile was found for middle and late adolescent males. For middle and late adolescent females, the leading reason for visits was special obstetrical-gynecological examination (12.8% and 21.1%), and the leading diagnosis resulting from visits was pregnancy (9.5% and 20.4%).

CONCLUSIONS

Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.