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Chu JN, Wong J, Bardach NS, Allen IE, Barr-Walker J, Sierra M, Sarkar U, Khoong EC. Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis. BMJ Qual Saf 2024; 33:456-469. [PMID: 38160059 PMCID: PMC11186734 DOI: 10.1136/bmjqs-2023-016295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/25/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND OBJECTIVE Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates. DATA SOURCES Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used. STUDY SELECTION Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only). DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis. MAIN OUTCOMES AND MEASURES Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period. RESULTS We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications. DISCUSSION Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients. PROSPERO REGISTRATION NUMBER CRD42022302871.
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Affiliation(s)
- Janet N Chu
- Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jeanette Wong
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Naomi S Bardach
- Pediatrics, University of California San Francisco, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
| | - Isabel Elaine Allen
- Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Jill Barr-Walker
- Zuckerberg San Francisco General Hospital and Trauma Center Library, San Francisco, California, USA
| | - Maribel Sierra
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Tendo, San Francisco, California, USA
| | - Urmimala Sarkar
- Medicine, University of California San Francisco, San Francisco, California, USA
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Elaine C Khoong
- Medicine, University of California San Francisco, San Francisco, California, USA
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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Akcan Yildiz L, Karaca Vural O, Tehci AK, Akca H, Kurt F, Akca Caglar A, Dibek Misirlioglu E. Pediatric emergency revisits of children with COVID-19. Postgrad Med 2022; 135:379-385. [PMID: 36516279 DOI: 10.1080/00325481.2022.2157634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study was conducted to reveal the characteristics of pediatric emergency revisits of children with COVID-19 and the factors associated with clinical worsening and hospitalization at the revisit. MATERIALS AND METHODS In pediatric emergency visits of children between July 2020 and March 2021 with COVID-19, the patients who had a revisit within 7 days were included in the study. Demographic and clinical characteristics, test results, and the relationship of these variables with clinical worsening and hospitalization at the revisit were investigated. RESULTS In 6779 children with COVID-19, 284 (4.1%) patients included in the study. 51.8% of the patients were male, the median age was 11.1 years, and median time to revisit time was 2.0 days. The rates of clinical worsening and hospitalization were 9.1% and 14.7%, respectively. Children younger than 24 months and those with chronic diseases were more commonly hospitalized at the revisit. Though the frequency of laboratory and radiologic testing at the revisit was significantly increased compared to the first presentation, tests did not play an important role in the decision-making processes. More than 85% of patients were clinically mild at the first presentation and revisit. CONCLUSIONS Children with a diagnosis of COVID-19 can revisit the emergency without evident clinical worsening. Since revisits cause increase in frequency of laboratory and radiological testing, preventing unnecessary revisits of children with COVID-19 can reduce the workload and cost of health care services. We may consider changing our perspective on revisit patients to make decisions based on clinical findings instead of obtaining for more laboratory tests.
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Affiliation(s)
| | | | - Ali Kansu Tehci
- University of Health Sciences Ankara City Hospital Pediatrics
| | - Halise Akca
- University of Yildirim Beyazit Ankara City Hospital, Pediatric Emergency Clinic
| | - Funda Kurt
- Ankara City Hospital Pediatric Emergency Clinic
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Parental Childhood Adversity and Pediatric Emergency Department Utilization: A Pilot Study. Pediatr Emerg Care 2022; 38:665-671. [PMID: 36375010 DOI: 10.1097/pec.0000000000002875] [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: 11/15/2022]
Abstract
OBJECTIVES Adverse childhood experiences (ACEs) including physical, emotional, or sexual abuse; neglect; and/or exposure to household instability have been associated with adult emergency department utilization, but the impact of parental ACEs on pediatric emergency department (PED) utilization has not been studied. The primary aim was to determine if parental ACEs impact resource utilization as measured by (1) frequency of PED utilization, (2) acuity of PED visits, and (3) 72-hour PED return rates. The secondary aim was to determine if resilience interacts with the impact of parental ACEs on PED utilization. METHODS This study is a cross-sectional survey using previously validated measures of ACEs, resiliency, and social determinants of health screening. Surveys were administered from October 17, 2019, to November 27, 2019, via iPad by research assistants in our institution's PEDs. Survey responses were linked to data abstracted from the electronic health record. Descriptive statistics were used to characterize our study population. Pearson correlation was used to identify correlation between ACEs, social determinants of health, and PED utilization measures. RESULTS A total of 251 parents had complete data. Parental ACEs were positively associated with frequency of PED visits (incidence rate ratio, 1.013). In addition, high levels of parental resilience attenuated the association between parental ACEs and the number of severe acuity visits and were associated with fewer 72-hour return visits (incidence rate ratio, 0.49). CONCLUSIONS Parental ACEs appear to be positively associated with frequency of PED utilization and inversely associated with higher-acuity PED visits and parental resiliency.
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Stokle M, Tinker RJ, Munro SP, Mullen N. Early reattenders to the paediatric emergency department: A prospective cohort study and multivariate analysis. J Paediatr Child Health 2022; 58:1616-1622. [PMID: 35726728 DOI: 10.1111/jpc.16061] [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] [Received: 02/21/2022] [Revised: 05/12/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Abstract
AIMS The rate of unplanned reattendances is used as an indicator of the quality of care delivered in a paediatric emergency department (PED). With early reattendance in the UK well above the national target of 1-5%, we aimed to identify the factors which predict unplanned early reattendance to the PED. METHODS This is a prospective, single-centre cohort study undertaken over 12 months. Data were collected on all patients who reattended the PED within 7 days of their initial visit as well as for a comparative cohort of patients with no visit in the preceding or subsequent 7 days. Multiple patient and departmental variables were recorded and analysed using a multivariate regression model. RESULTS There were a total of 19 420 index visits to the PED, of which 1461 patients had an unscheduled reattendance within 7 days - a rate of 7.5%. Factors associated with unplanned but related reattendance include young age and diagnosis with a respiratory or other medical illness. Interestingly, the grade of clinician appeared to be relevant with patients seen by junior members of the medical team less likely to reattend. Acuity of illness was not a significant factor. A substantial number of unplanned early reattenders (36.3%) would have been missed had a time period of 72 h been used rather than 7 days. CONCLUSIONS This study identifies the typical patient who will have an unplanned, related early reattendance to a PED. This study also supports the use of a 7-day time period when using early reattendance as a performance indicator.
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Affiliation(s)
- Matthew Stokle
- Paediatric Emergency Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom
| | - Rory J Tinker
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Samuel P Munro
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Niall Mullen
- Paediatric Emergency Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom
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Namgung M, Lee DH, Bae SJ, Chung HS, Park JY, Kim K, Lee CA, Kim DH, Kim EC, Lim JY, Han SS, Choi YH. A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods. CHILDREN 2022; 9:children9071003. [PMID: 35883987 PMCID: PMC9322694 DOI: 10.3390/children9071003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 11/24/2022]
Abstract
Unscheduled revisits to emergency departments (EDs) are important because they indicate the quality of emergency care. However, the characteristics of pediatric patients visiting EDs changed during the coronavirus disease (COVID-19) pandemic, and these changes may have affected their revisit patterns. Therefore, we aimed to compare the ED revisit patterns of pediatric patients between the pre-COVID-19 and COVID-19 periods. This retrospective multicenter study included patients aged below 18 years who visited the ED in the pre-COVID-19 and COVID-19 periods. ED revisit rates were analyzed using five age groups and three visit-revisit intervals. In the pre-COVID-19 period, the revisit rates decreased with increasing age. In the COVID-19 period, the revisit rates were the lowest for the group aged 4–6 years, and the rates increased for those aged ≥7 years. In conclusion, there were changes in the patterns of revisit rates of pediatric patients according to age between the pre-COVID-19 and COVID-19 periods. Therefore, it is necessary to identify the reasons for revisits according to age and establish strategies to reduce the revisit rates of pediatric patients.
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Affiliation(s)
- Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
- Correspondence: ; Tel.: +82-2-2610-6751
| | - Sung Jin Bae
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ho Sub Chung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ji Young Park
- Department of Pediatrics, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Keon Kim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Korea;
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, Seoul 01830, Korea;
| | - Eui Chung Kim
- CHA Bundang Medical Center, Department of Emergency Medicine, Seongnam-si 13496, Korea;
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, Seoul 06591, Korea;
| | - Sang Soo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon-si 14584, Korea;
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea;
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The Role of Immigrant Admission Classes on the Health and Well-being of Immigrants and Refugees in Canada: A Scoping Review. J Immigr Minor Health 2022; 24:1045-1060. [PMID: 35303219 DOI: 10.1007/s10903-022-01352-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2022] [Indexed: 10/18/2022]
Abstract
Many countries offer different pathways through which migrants can enter a new country. In Canada, there are three main immigrant admission classes: economic, family, and refugee. Previous research suggests that there are differences in health outcomes among various subgroups of migrants. A scoping review was conducted to characterize the role of immigrant admission classes on the health and well-being of immigrants and refugees in Canada. MEDLINE, Embase, PsycINFO, Sociological Abstracts, and EconLit databases were searched for quantitative studies published in English after 1990. The screening and selection process identified 27 relevant studies. Studies were categorized into four key reported outcomes: health care and services utilization, self-rated health and mental health, medical conditions and chronic illnesses, and social integration and satisfaction. Findings confirm that certain subgroups have worse health outcomes after arrival, particularly refugees, family class and other dependent immigrants. Health outcomes vary significantly across immigrant subgroups defined by the admission class through which they entered Canada.
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Nijman RG, Borensztajn DH, Zachariasse JM, Hajema C, Freitas P, Greber-Platzer S, Smit FJ, Alves CF, van der Lei J, Steyerberg EW, Maconochie IK, Moll HA. A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study. PLoS One 2021; 16:e0254366. [PMID: 34264983 PMCID: PMC8281990 DOI: 10.1371/journal.pone.0254366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department. METHODS AND FINDINGS A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit ('index' visit), in 2012-2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7-2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65-0.74) and summary calibration slope of 0.83 (95% CI 0.67-0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87-5.01) and specificity 0.96 (95% CI 0.95-0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25-0.35), sensitivity 0.88 (95% CI 0.86-0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68-0.75) and summary calibration slope of 0.84 (95% CI 0.71-0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded. CONCLUSION We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.
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Affiliation(s)
- Ruud G. Nijman
- Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College of Science, Technology and Medicine, Faculty of Medicine, London, United Kingdom
- Department of Paediatric Emergency Medicine, St Mary’s Hospital–Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Dorine H. Borensztajn
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Joany M. Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Carine Hajema
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Paulo Freitas
- Intensive Care Unit, Hospital Prof. Dr. Fernando Fonseca, Lisbon, Portugal
| | - Susanne Greber-Platzer
- Department of Paediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Frank J. Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Claudio F. Alves
- Department of Paediatrics, Hospital Prof. Dr. Fernando Fonseca, Lisbon, Portugal
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus MC- University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ewout W. Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ian K. Maconochie
- Department of Paediatric Emergency Medicine, St Mary’s Hospital–Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Henriette A. Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
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Sheriff F, Agarwal A, Thipse M, Radhakrishnan D. Hot spots for pediatric asthma emergency department visits in Ottawa, Canada. J Asthma 2021; 59:880-889. [PMID: 33567912 DOI: 10.1080/02770903.2021.1887891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Pediatric asthma emergency department (ED) visits and repeat visits place a substantial burden on healthcare. National and provincial level studies demonstrate geographic variation in asthma ED visits and links to marginalization, but preclude translation into practical targeting of healthcare delivery. It is important to understand the relationship between pediatric asthma ED visits and marginalization at a more granular level. To map the city-level geographic variation in pediatric asthma ED visit and re-visit rates at the Children's Hospital of Eastern Ontario (CHEO) in Ottawa, Canada and the relationship with marginalization. METHODS We performed a single center retrospective cohort study of children ages 1-17 with one or more ED visits for asthma at the CHEO in Ottawa. Using postal codes, we linked patients to census tracts. Per census tract, we mapped pediatric asthma ED visit and re-visit rates within one year and identified overlap with the Ontario Marginalization Index. RESULTS Of 1,620 children with an index ED visit, 18.5% had a repeat ED visit. We identified 10 hot spot census tracts each for pediatric asthma ED visit and re-visit rates. We identified an overlap between urban hot spots and areas with high ethnic concentration or low dependency. CONCLUSION At a granular, city-wide level, pediatric asthma ED visit and re-visit rates are heterogeneous. Urban hot spots, in contrast to rural, have more overlap with marginalization, especially ethnic concentration. These methods can be used in other jurisdictions to inform practical community strategies for geographically-targeted prevention of pediatric asthma-related ED visits in vulnerable areas.Abbreviations:ED:Emergency department;CHEO:Children's Hospital of Eastern Ontario;PRAM:Pediatric Respiratory Assessment Measure;ON-Marg:Ontario Marginalization Index;SES:Socioeconomic status;US:United States. Supplemental data for this article can be accessed at publisher's website.
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Affiliation(s)
- Falana Sheriff
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Amisha Agarwal
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Madhura Thipse
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Dhenuka Radhakrishnan
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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Cochran AL, Rathouz PJ, Kocher KE, Zayas-Cabán G. A latent variable approach to potential outcomes for emergency department admission decisions. Stat Med 2019; 38:3911-3935. [PMID: 31184788 DOI: 10.1002/sim.8210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 04/16/2019] [Accepted: 05/06/2019] [Indexed: 11/07/2022]
Abstract
In emergency departments (EDs), care providers continuously weigh admissions against continued monitoring and treatment often without knowing their condition and health needs. To understand the decision process and its causal effect on outcomes, an observational study must contend with unobserved/missing information and a lack of exchangeability between admitted and discharged patients. Our goal was to provide a general framework to evaluate admission decisions from electronic healthcare records (EHRs). We describe admission decisions as a decision-making process in which the patient's health needs is a binary latent variable. We estimate latent health needs from EHR with only partial knowledge of the decision process (ie, initial evaluation, admission decision, length of stay). Estimated latent health needs are then used to understand the admission decision and the decision's causal impact on outcomes. For the latter, we assume potential outcomes are stochastically independent from the admission decision conditional on latent health needs. As a case study, we apply our approach to over 150 000 patient encounters with the ED from the University of Michigan Health System collected from August 2012 through July 2015. We estimate that while admitting a patient with higher latent needs reduces the 30-day risk of revisiting the ED or later being admitted through the ED by over 79%, admitting a patient with lower latent needs actually increases these 30-day risks by 3.0% and 7.6%, respectively.
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Affiliation(s)
- Amy L Cochran
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Paul J Rathouz
- Department of Population Health, The University of Texas at Austin, Austin, Texas
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Gabriel Zayas-Cabán
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
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Doan Q, Goldman RD, Meckler GD. Management practice-related and modifiable factors associated with paediatric emergency return visits. Paediatr Child Health 2019; 24:e1-e7. [PMID: 30792602 PMCID: PMC6376311 DOI: 10.1093/pch/pxy039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED). METHODS We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors. RESULTS There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process. CONCLUSIONS Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.
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Affiliation(s)
- Quynh Doan
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia
| | - Ran D Goldman
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia
| | - Garth D Meckler
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia
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Selotlegeng L. The impact of parental migration on injuries among left behind young people aged 10 years to 24 years in Botswana. Biosci Trends 2018; 12:126-131. [PMID: 29760356 DOI: 10.5582/bst.2018.01055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There has been little evidence of the relationship between children and absence of parents in Botswana literature; and it is still the case that absence of parents increases the risk of injuries to their children. The aim of this study is to investigate the impact of parental migration among left behind young people aged 10 years to 24 years in Botswana and examine patterns of injuries from immigrant families. This is a population-based crosssection from which a dataset was created by compiling data from two different sources for the period of 2010 to 2015. All the variables were transformed into natural logarithms so as to avoid outliers and normalize the variables. All statistical modeling was carried out using Statistical Analysis System version 6.1. Left behind young people were associated with higher risk of injuries especially in motor vehicle accidents 391(40%), fire 264 (27%), and burns 162 (16%) except for drowning, machinery and poisoning. Parental migration is the most important issue in the total number of injuries. Correlation coefficient shows that non-left behind, the greater the chance to be classified under the poisoning cases (r = 0.888) and is lower compared to the left behind (r = 0.471). This study shows clearly that injuries take an insufficiently high toll on children's health and on society. Additionally, if parental migration trends continue, Botswana's burden of injuries are expected to rise in the next 10 years.
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Affiliation(s)
- Lesego Selotlegeng
- United Nation Economic Commission for Africa.,Institute of Development Management Idm (Botswana)
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To T, Zhu J, Ryckman K, Gershon A. Risk Factors for Return to the Emergency Department for Asthma: A Population-Based Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1907-1913.e4. [PMID: 29715564 DOI: 10.1016/j.jaip.2018.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 04/02/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND A substantial proportion of patients with asthma return after being discharged from the emergency department (ED). Given the high economic burden of acute care claims, and the impact on productivity and quality of life, a better understanding of risk factors for ED return is of interest. OBJECTIVE To quantify the rate and determine factors associated with return to the ED for asthma within 1 year of an initial ED visit for asthma. METHODS Individuals aged 5 to 99 years living in Ontario, Canada, with an ED visit for asthma in the period 2008 to 2014 were included. Descriptive statistics were used to compare those with an ED return with those without an ED return. An adjusted modified Poisson regression model was used to estimate the relative risk of ED return for asthma within 1 year after the initial discharge. RESULTS In total, 58,366 individuals met the inclusion criteria. At 1-year follow-up, 12.1% returned to the ED at least once. Younger age, being materially deprived, and having chronic obstructive pulmonary disease were significantly associated with increased risk of ED return within 1 year after the initial visit. CONCLUSIONS Nearly 1 in 8 individuals with a first ED visit for asthma returned to the ED within a year of the initial ED discharge. Targeting those at risk for ED return may help improve health care costs, productivity, and quality of life.
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Affiliation(s)
- Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Jingqin Zhu
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kandace Ryckman
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrea Gershon
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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The shrinking health advantage: unintentional injuries among children and youth from immigrant families. BMC Public Health 2017; 18:73. [PMID: 28764763 PMCID: PMC5540344 DOI: 10.1186/s12889-017-4612-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 07/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immigrants typically arrive in good health. This health benefit can decline as immigrants adopt behaviours similar to native-born populations. Risk of injury is low in immigrants but it is not known whether this changes with increasing time since migration. We sought to examine the association between duration of residence in Canada and risk of unintentional injury. METHODS Population-based cross-sectional study of children and youth 0 to 24 years in Ontario, Canada (2011-2012), using linked health and administrative databases. The main exposure was duration of Canadian residence (recent: 0-5 years, intermediate: 6-10 years, long-term: >10 years). The main outcome measure was unintentional injuries. Cause-specific injury risk by duration of residence was also evaluated. Poisson regression models estimated rate ratios (RR) for injuries. RESULTS 999951 immigrants were included with 24.2% recent and 26.4% intermediate immigrants. The annual crude injury rates per 100000 immigrants were 6831 emergency department visits, 151 hospitalizations, and 4 deaths. In adjusted models, recent immigrants had the lowest risk of injury and risk increased over time (RR 0.79; 95% CI 0.77, 0.81 recent immigrants, RR 0.90; 95% CI 0.88, 0.92 intermediate immigrants, versus long-term immigrants). Factors associated with injury included young age (0-4 years, RR 1.30; 95% CI 1.26, 1.34), male sex (RR 1.52; 95% CI 1.49, 1.55), and high income (RR 0.93; 95% CI 0.89, 0.96 quintile 1 versus 5). Longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot object/scald burns, machinery-related injuries, non-motor vehicle bicycle and pedestrian injuries. The risk of these latter injuries did not change significantly with increasing duration of residence in Canada. Risk of drowning was highest in recent immigrants. CONCLUSIONS Risk of all-cause and most cause-specific unintentional injuries in immigrants rises with increasing time since migration. This indicates the need to develop strategies for maintaining the immigrant health advantage over time while balancing the desire to support integration, active living, and healthy child development.
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Saunders NR, Lee H, Macpherson A, Guan J, Guttmann A. Risk of firearm injuries among children and youth of immigrant families. CMAJ 2017; 189:E452-E458. [PMID: 28385861 DOI: 10.1503/cmaj.160850] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Firearm injuries contribute to substantial morbidity and mortality. The immigrant paradox suggests that, despite being more socially disadvantaged, immigrants are less likely than nonimmigrants to have poor outcomes. We tested the association of immigrant characteristics with firearm injuries among children and youth. METHODS We conducted a population-based cohort study involving residents of Ontario aged 24 years and younger from 2008-2012 using health and administrative databases. We estimated rate ratios of unintentional and assault-related firearm injuries by immigrant status using Poisson regression models with Generalized Estimating Equations. RESULTS We included 15 866 954 nonimmigrant and 4 551 291 immigrant person-years in our analysis. Nonimmigrant males had 1032 unintentional (12.4 per 100 000, 95% confidence interval [CI] 11.7-13.2) and 304 assault-related (3.6 per 100 000, 95% CI 3.2-4.0) firearm injuries. Immigrant males had 148 unintentional (7.2 per 100 000, 95% CI 6.1-8.5) and 113 assault-related (5.5 per 100 000, 95% CI 4.5-6.6) firearm injuries. Compared with nonimmigrants, immigrants had a lower rate of unintentional firearm injury (adjusted rate ratio 0.5, 95% CI 0.4-0.6) but a similar rate of assault-related firearm injury. Among immigrants, refugees had a 43% higher risk of assault-related firearm injury compared with nonrefugees (adjusted rate ratio 1.4, 95% CI 1.0-2.0). Immigrants from Central America and Africa accounted for 68% of immigrants with assault-related firearm injuries. INTERPRETATION Compared with nonimmigrants, immigrant children and youth had a lower risk of unintentional firearm injury, although the risk of assault-related firearm injury was higher among refugees and immigrants from Central America and Africa. The results suggest that prevention strategies for firearm safety should target nonimmigrant youth as well as these newly identified high-risk immigrant populations.
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Affiliation(s)
- Natasha R Saunders
- Department of Pediatrics (Saunders, Guttmann), The Hospital for Sick Children and University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Lee, Macpherson, Guan, Guttmann); Faculty of Health (Macpherson), School of Kinesiology and Health Science, York University; Child Health Evaluative Sciences (Saunders, Guttmann), SickKids Research Institute, Toronto, Ont
| | - Hannah Lee
- Department of Pediatrics (Saunders, Guttmann), The Hospital for Sick Children and University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Lee, Macpherson, Guan, Guttmann); Faculty of Health (Macpherson), School of Kinesiology and Health Science, York University; Child Health Evaluative Sciences (Saunders, Guttmann), SickKids Research Institute, Toronto, Ont
| | - Alison Macpherson
- Department of Pediatrics (Saunders, Guttmann), The Hospital for Sick Children and University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Lee, Macpherson, Guan, Guttmann); Faculty of Health (Macpherson), School of Kinesiology and Health Science, York University; Child Health Evaluative Sciences (Saunders, Guttmann), SickKids Research Institute, Toronto, Ont
| | - Jun Guan
- Department of Pediatrics (Saunders, Guttmann), The Hospital for Sick Children and University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Lee, Macpherson, Guan, Guttmann); Faculty of Health (Macpherson), School of Kinesiology and Health Science, York University; Child Health Evaluative Sciences (Saunders, Guttmann), SickKids Research Institute, Toronto, Ont
| | - Astrid Guttmann
- Department of Pediatrics (Saunders, Guttmann), The Hospital for Sick Children and University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Lee, Macpherson, Guan, Guttmann); Faculty of Health (Macpherson), School of Kinesiology and Health Science, York University; Child Health Evaluative Sciences (Saunders, Guttmann), SickKids Research Institute, Toronto, Ont.
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Kilicaslan O, Sönmez FT, Gunes H, Temizkan RC, Kocabay K, Saritas A. Short Term Unscheduled Revisits to Paediatric Emergency Department - A Six Year Data. J Clin Diagn Res 2017; 11:SC12-SC15. [PMID: 28511472 DOI: 10.7860/jcdr/2017/25098.9484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/06/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Reviewing the reasons for return visits within 24 hours is a very important method of determining possible problems of emergency health care. Several causes stay behind unscheduled emergency return visits. Therefore, identifying these factors is crucial to set strategies in order to decrease the number of unnecessary visits. AIM To define the characteristics of the patients returning to the Paediatric Emergency Department (PED) within 24 hours via determining rate, number and demographic data of patients. MATERIALS AND METHODS The present study design involves retrospective data collection of patients who returned to PED within 24 hours after being discharged. Data was included over six year period and was collected from July 1, 2010 to June 30, 2016. The data was analysed with SPSS17.0 statistical package for windows. RESULTS A total of 1994 patients returned to PED within 24 hours from July 1, 2010 to June 30, 2016. The most common group of revisiting patients were toddlers (aged 0-2-year old), n=1168 (58.5%), and the least number represented young adolescents (aged 15-18-year old), n=82 (4.1%). Number of patients returning to PED in 24 hours has significantly increased within years from approximately 90 patients to 720 (p<0.05). This increase in number was observed in all and each age group (from 0-18 years of age) without any exception. Seasonal distribution of the patients showed no significant difference (p>0.05) for each age, but again, presented definite negative correlation with age (the older is the patient group, the less is the number of revisits). The most common time for revisits was 17-24 hours after first discharge from PED, n=1277 (64.04%). CONCLUSION The number of return visits is increasing over the years. The younger the patient is, more likely is the risk of unscheduled revisit to PED. Most of the patients returned to PED in 17 to 24 hours after discharge.
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Affiliation(s)
- Onder Kilicaslan
- Faculty, Department of Pediatric Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Feruza Turan Sönmez
- Faculty, Department of Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Harun Gunes
- Faculty, Department of Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Ramazan Cahit Temizkan
- Faculty, Department of Pediatric Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Kenan Kocabay
- Faculty, Department of Pediatric Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Ayhan Saritas
- Faculty, Department of Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
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Truong M, Meckler G, Doan QH. Emergency Department Return Visits Within a Large Geographic Area. J Emerg Med 2017; 52:801-808. [PMID: 28228344 DOI: 10.1016/j.jemermed.2017.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/30/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area. OBJECTIVE We sought to measure the frequency of pediatric RTEDs and describe their directional pattern across centers in a large catchment area. METHODS We conducted a multicenter, retrospective cross-sectional study of pediatric emergency visits in the Vancouver lower mainland within 1 year. Visits were linked across study sites, including one pediatric quaternary care referral center and 17 sites ranging from large regional centers to smaller community emergency departments (EDs). Returns were defined as subsequent visits to any site with a compatible diagnosis within 7 days of an index visit. RESULTS Among a total of 139,278 index ED visits by children, 12,133 (8.7% [95% confidence interval 8.6-8.9%]) were associated with 14,645 return visits to an ED. Three quarters of all index visits occurred at a general ED center, of which 8.9% had at least one RTED and 22% of these returns occurred at the pediatric ED (PED). Among PED index visits, 8.2% had at least one RTED and 13.6% of these returned to a general center. Overall, 38.9% of all RTEDs occurred at the PED. Multivariate regression did not identify any statistically significant association between ED crowding measures and likelihood of RTEDs. CONCLUSIONS Compared to single-center studies, this study linking hospitals within a large geographic area identified a higher proportion of RTEDs with a disproportionate burden on the PED.
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Affiliation(s)
- Mimi Truong
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Garth Meckler
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Emergency Medicine, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Quynh H Doan
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Emergency Medicine, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
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Saunders NR, Macpherson A, Guan J, Sheng L, Guttmann A. Unintentional injuries in children and youth from immigrant families in Ontario, Canada: a population-based cross-sectional study. CMAJ Open 2017; 5:E90-E96. [PMID: 28401124 PMCID: PMC5378502 DOI: 10.9778/cmajo.20160099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Unintentional injury is the leading cause of childhood death. Injury is associated with a number of sociodemographic characteristics, but little is known about risk in immigrants. Our objective was to examine the association between family immigrant status and unintentional injury in children and youth. METHODS We performed a population-based, cross-sectional study involving children and youth (age 0-24 yr) residing in Ontario from 2008 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by family immigrant status. Unintentional injury events (e.g., emergency department visits, admissions to hospital, deaths) were analyzed using Poisson regression models to estimate rate ratios (RRs) for injury by immigrant status. RESULTS Annualized injury rates were 11 749 emergency department visits per 100 000 population, 267 hospital admissions per 100 000 population and 12 deaths per 100 000 population. Injury rates were lower among immigrants across all causes of unintentional injury (adjusted RR 0.56, 95% confidence interval [CI] 0.54-0.59). Among nonimmigrants, lowest neighbourhood income quintile was associated with the highest rates (RR 1.13, 95% CI 1.08-1.18, quintile 5 v. 1); among immigrants, lowest income quintile was associated with the lowest rates of injury (RR 0.88, 95% CI 0.82-0.94, quintile 5 v. 1). Highest rates of injury for nonimmigrants were among adolescents (age 10-14 yr, RR 1.23, 95% CI 1.18-1.28; v. 20-24 yr), but for immigrants, was highest among young children (0-4 yr RR 1.23, 95% CI 1.16-1.31; v. 20-24 yr). INTERPRETATION Rates of unintentional injury are lower among immigrant than among Canadian-born children, supporting a healthy immigrant effect. Socioeconomic status and age have different associations with injury risk, suggesting alternative causal pathways for injuries in immigrant children and youth.
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Affiliation(s)
- Natasha Ruth Saunders
- The Hospital for Sick Children (Saunders, Guttmann); Department of Pediatrics (Saunders, Guttmann), University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Macpherson, Guan, Sheng, Guttmann); York University (Macpherson); Institute of Health Policy, Management and Evaluation (Guttmann); Dalla Lana School of Public Health (Guttmann), University of Toronto; Child Health Evaluative Sciences (Guttmann), SickKids Research Institute, Toronto, Ont
| | - Alison Macpherson
- The Hospital for Sick Children (Saunders, Guttmann); Department of Pediatrics (Saunders, Guttmann), University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Macpherson, Guan, Sheng, Guttmann); York University (Macpherson); Institute of Health Policy, Management and Evaluation (Guttmann); Dalla Lana School of Public Health (Guttmann), University of Toronto; Child Health Evaluative Sciences (Guttmann), SickKids Research Institute, Toronto, Ont
| | - Jun Guan
- The Hospital for Sick Children (Saunders, Guttmann); Department of Pediatrics (Saunders, Guttmann), University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Macpherson, Guan, Sheng, Guttmann); York University (Macpherson); Institute of Health Policy, Management and Evaluation (Guttmann); Dalla Lana School of Public Health (Guttmann), University of Toronto; Child Health Evaluative Sciences (Guttmann), SickKids Research Institute, Toronto, Ont
| | - Lisa Sheng
- The Hospital for Sick Children (Saunders, Guttmann); Department of Pediatrics (Saunders, Guttmann), University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Macpherson, Guan, Sheng, Guttmann); York University (Macpherson); Institute of Health Policy, Management and Evaluation (Guttmann); Dalla Lana School of Public Health (Guttmann), University of Toronto; Child Health Evaluative Sciences (Guttmann), SickKids Research Institute, Toronto, Ont
| | - Astrid Guttmann
- The Hospital for Sick Children (Saunders, Guttmann); Department of Pediatrics (Saunders, Guttmann), University of Toronto; Institute for Clinical Evaluative Sciences (Saunders, Macpherson, Guan, Sheng, Guttmann); York University (Macpherson); Institute of Health Policy, Management and Evaluation (Guttmann); Dalla Lana School of Public Health (Guttmann), University of Toronto; Child Health Evaluative Sciences (Guttmann), SickKids Research Institute, Toronto, Ont
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