Lack of a regular source of care among children using a public hospital emergency department

Evaluating the Impact of the Healthy Beginnings System of Care Model on Pediatric Emergency Department Utilization

OBJECTIVE

The aim of this study was to evaluate whether enrollment in the Healthy Beginnings System of Care (SOC) model is associated with a decrease in emergency department (ED) visits among children aged 6 months to 5.5 years.

METHODS

A retrospective, longitudinal study of ED utilization was conducted among children enrolled in the Healthy Beginnings SOC model between February 2011 and May 2013. Using medical records obtained from a children's hospital in Atlanta, the rate of ED visits per quarter was examined as the main outcome. A multilevel, multivariate Poisson model, with family- and child-level random effects, compared ED utilization rates before and after enrollment. Adjusted rate ratios and 95% confidence intervals were calculated after controlling for sociodemographic confounders.

RESULTS

The effect of SOC enrollment on the rate of ED visits differed by income level of the primary parent. The rate of ED visits after enrollment was not significantly different than the rate of ED visits before enrollment for children whose primary parent had an annual income of less than $5000 (P = 0.298), $20,000 to $29,999 (P = 0.199), or $30,000 or more (P = 0.117). However, for the children whose primary parent's annual income was $5000 to $19,999, the rate of ED visits after enrollment was significantly higher than the rate of ED visits before enrollment (adjusted rate ratio, 1.48; 95% confidence interval, 1.17-1.87).

CONCLUSIONS

Enrollment in the SOC model does not appear to decrease the rate of ED visits among enrolled children. Additional strategies, such as education sessions on ED utilization, are needed to reduce the rate of ED utilization among SOC-enrolled children.

Emergency department presentations by Aboriginal children: issues for consideration for appropriate health services

AIM

This study describes the presentations made to the Sydney Children's Hospital (SCH) Emergency Department (ED) by local Aboriginal and Torres Strait Islander (Aboriginal) children with particular reference to children who present frequently or whose presentation was preventable.

METHODS

Data from the SCH ED Information System were extracted for all presentations made by children who identified as Aboriginal, aged between 0-15 years, who presented between 2005-2008. Presentations were coded according to the presenting problem, diagnosis, outcome, and whether the presentations were potentially preventable. Preventable presentations include those presentations considered to be avoidable and those that could have been managed by a local primary care or community service.

RESULTS

There were 1252 presentations to the SCH ED by 453 Aboriginal children aged 0-15 years. More than 50% of children presented more than once. Seventy-nine children presented more than five times. Nearly 45% of presentations were coded as potentially preventable.

CONCLUSIONS

A significant proportion of ED presentations were potentially preventable with the use of culturally appropriate and accessible local community and primary health care services and better referral pathways back to these services. Community engagement is required to raise awareness of common presentations and to look at strategies to prevent common problems both occurring and presenting to the ED. This will enhance the health of urban Aboriginal children.

Specialist home-based nursing services for children with acute and chronic illnesses

BACKGROUND

Specialist paediatric home-based nursing services have been proposed as a cost-effective means of reducing distress resulting from hospital admissions, while enhancing primary care and reducing length of hospital stay. This review is an update of our original review, which was published in 2006.

OBJECTIVES

To evaluate specialist home-based nursing services for children with acute and chronic illnesses.

SEARCH METHODS

We searched the following databases in February 2012: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012 Issue 2, Ovid MEDLINE, EMBASE, PsycINFO, CINAHL and Sociological Abstracts. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of children from birth to age 18 years with acute or chronic illnesses allocated to specialist home-based nursing services compared with conventional health care. Outcomes included utilisation of health care, physical and mental health, satisfaction, adverse health outcomes and costs.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data from the studies independently and resolved any discrepancies by recourse to a third author. Meta-analysis was not appropriate because of the clinical diversity of the studies and the lack of common outcome measures.

MAIN RESULTS

We screened 4226 titles to yield seven RCTs with a total of 840 participants. Participants, interventions and outcomes were diverse. No significant differences were reported in health outcomes; two studies reported a reduction in the hospital stay with no difference in the hospital readmission rates. Three studies reported a reduction in parental anxiety and improvement in child behaviours was reported in three studies. Overall increased parental satisfaction was reported in three studies. Also, better parental coping and family functioning was reported in one study. By contrast, one study each reported no impact on parental burden of care or on functional status of children. Home care was reported as more costly for service providers with substantial cost savings for the family in two studies, while one study revealed no significant cost benefits for the family.

AUTHORS' CONCLUSIONS

Current research does not provide supporting evidence for a reduction in access to hospital services or a reduction in hospital readmission rate for children with acute and chronic illnesses using specialist home-based nursing services; however, the only summary finding across a few studies was that there is a significant decrease in length of hospitalisation. The preliminary results show no adverse impact on physical health outcomes and a number of papers reported improved satisfaction with home-based care. Further trials are required, measuring health, satisfaction, service utilisation and long-term costs.

The relationship between parent health literacy and pediatric emergency department utilization: a systematic review

BACKGROUND

Low health literacy in parents can potentially impact understanding of a child's diagnosis and treatment course. No reviews have addressed parent health literacy in the emergency department (ED), the relationship between parent health literacy and child ED utilization, or the impact of low literacy interventions on child ED utilization.

OBJECTIVE

To systematically evaluate the peer-reviewed literature pertaining to parental health literacy and ED utilization. The following key questions were addressed: question (Q) 1) What is the prevalence of low health literacy, as estimated by validated health literacy measures, of parents in the ED? Q2) Is parent low health literacy related to ED use for children? Q3) Do low literacy interventions targeting parents likely to have low health literacy affect ED use for children?

DATA SOURCES

The authors reviewed 483 unduplicated titles and abstracts published between 1980 and May 2012 using PubMed and CINAHL, with 117 retained for full review and 17 included in the final analytic review.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

All included articles had a valid measure of parent health literacy and a Q1) descriptive measurement of the population, Q2) ED utilization, or Q3) utilized a low literacy educational intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author extracted data verified by a second author. Studies were rated for quality by both authors.

RESULTS

Q1) A median of 30% (interquartile range 22-36%) of parents in the ED possesses low health literacy. Q2) Studies investigating the relationship between health literacy and ED yielded mixed results. Q3) Seven of 8 low literacy interventions were associated with a reduction in ED use. Random effects pooled odds ratios from 6 studies showed intervention effectiveness (odds ratio 0.35; 95% CI 0.15-0.81).

LIMITATIONS

No intervention studies measured health literacy, limiting the ability to determine whether the low literacy intervention targeted health literacy.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Roughly 1 in 3 parents of children presenting to the ED have low health literacy. Importantly, interventions targeting parents likely to have low health literacy have an impact in reducing ED utilization.

Paid sick days and health care use: an analysis of the 2007 national health interview survey data

BACKGROUND

In identifying factors of health care use, past research has focused on individual-level characteristics or on the health care system itself. This study investigates whether access to paid sick days, an amenable environmental factor outside the health care system, is associated with primary and emergency care use.

METHODS

A nationally representative sample of 14,302 U.S. working adults extracted from the 2007 National Health Interview Survey data was used. Multiple logistic regressions were performed, controlling for demographic variables, health conditions and status, and access to health care.

RESULTS

Workers with lower socioeconomic status, poorer health status, or without health insurance or regular places for care were more likely to lack paid sick days than higher-status workers. For all U.S. working adults, access to paid sick days benefits was significantly associated with increased use of outpatient care but not with reduced use of ER. For U.S. working adults with health insurance coverage, access to paid sick days benefits was significantly associated with increased use of outpatient care and reduced use of emergency care.

CONCLUSIONS

A public policy mandating paid sick days may help facilitate timely access to primary care, reduce avoidable emergency care use, and reduce health disparities among workers.

Primary care quality and subsequent emergency department utilization for children in Wisconsin Medicaid

OBJECTIVE

Children enrolled in Medicaid have disproportionately high emergency department (ED) visit rates. Despite the growing importance of patient reported quality-of-care assessments, little is known about the association between parent-reported quality of primary care and ED utilization for these high-risk children. Our goal was to determine the association between parent-reported primary care quality and subsequent ED utilization for children in Medicaid.

METHODS

We studied a retrospective cohort of children enrolled in Wisconsin Medicaid. Parents of children sampled during fall 2002 and fall 2004 completed Consumer Assessment of Healthcare Providers and Systems surveys assessing their child's primary care quality in 3 domains: family centeredness, timeliness, and realized access. Primary outcomes were the rates of subsequent nonurgent and urgent ED visits, extracted from claims data for the year after survey completion. Negative binomial regression was used to determine the association between the domains of care and ED utilization.

RESULTS

A total of 5468 children were included. High-quality family centeredness was associated with a 27% (95% confidence interval [95% CI] 11%-40%) lower nonurgent ED visit rate, but no lowering of the urgent visit rate. High-quality timeliness was associated with 18% (95% CI, 3%-31%) lower nonurgent and 18% (95% CI, 1%-33%) lower urgent visit rates. High-quality realized access was associated with a 27% (95% CI, 8%-43%) lower nonurgent visit rate and a 33% (95% CI, 14%-48%) lower urgent visit rate.

CONCLUSIONS

Parent-reported high-quality timeliness, family centeredness, and realized access for a publicly insured child are associated with lower nonurgent ED, with high-quality timeliness and realized access associated with lower urgent ED utilization.

The Impact of Managed Care Enrollment on Emergency Department Use Among Children With Special Health Care Needs

BACKGROUND

Many states recently have experimented with managed care as a way both to control costs and to enhance continuity of care in their publicly financed programs. A few states have applied managed care models to the care of chronically ill children. One marker for the effects of managed care is changes in use of the emergency department (ED).

OBJECTIVE

We sought to determine whether a managed care program can reduce ED use for children with chronic health problems.

SUBJECTS

We studied chronically ill children who were dually enrolled in Michigan's Title V program for children with special health care needs and Medicaid and who were enrolled in a managed care option at some time during the study period. The managed care model emphasized care coordination and did not include strong financial incentives for utilization and cost control. Sample consisted of 8580 person-months.

METHOD

We used a fixed-effect negative binomial Poisson regression model to compare ED use before and after joining a managed care plan to test whether managed care use was associated with reduced likelihood of ED use.

RESULTS

Managed care enrollment was associated with a 23% reduction in the incidence of ED use among children dually enrolled in Medicaid and Title V.

CONCLUSIONS

A managed care model is associated with statistically significant and substantive reductions in observed use of ED care within an important population of children facing chronic illness.

Specialist home-based nursing services for children with acute and chronic illnesses

BACKGROUND

Specialist paediatric home-based nursing services have been proposed as a cost-effective means of reducing trauma resulting from hospital admissions, while enhancing primary care and reducing length of hospital stay.

OBJECTIVES

To evaluate specialist home-based nursing services for children with acute and chronic illnesses.

SEARCH STRATEGY

Electronic searches were made of CENTRAL (Cochrane Central Register of Controlled Trials) 2005 (Issue 2); MEDLINE (1966 to August 2005); EMBASE (1980 to August 2005); PsycINFO (1887 to August 2005); CINAHL (1982 to August 2005); Sociological Abstracts (1963 to August 2005). Optimally sensitive search strategies for randomised controlled trials (RCTs) were combined with medical subject headings and text words specific for ambulatory paediatrics, nursing outreach and 'hospital in the home', and no language restrictions were applied.

SELECTION CRITERIA

RCTs of children aged 0-18 with acute or chronic illnesses allocated to specialist home-based nursing services compared with conventional medical care. Outcomes included utilisation of health care, physical and mental health, satisfaction, adverse health outcomes and costs.

DATA COLLECTION AND ANALYSIS

Meta-analysis was not appropriate because of the clinical diversity and lack of common outcomes measures

MAIN RESULTS

1655 titles yielded 5 RCTs with a total of 771 participants. Participants, interventions and outcomes were diverse. No significant differences were reported in health outcomes; two studies reported improvements in child and parental anxiety; one study reported no significant difference in readmissions; two studies reported significantly fewer bed days; increased satisfaction was reported ; home care was more costly for service providers, but less expensive for parents.

AUTHORS' CONCLUSIONS

While current research does not provide definitive support for specialist home-based nursing services in reducing access to hospital services or length of stay, preliminary results show no adverse impact on physical health outcomes and a number of papers reported improved satisfaction with home-based care. Further trials are required, measuring health, satisfaction, service utilisation and long-term costs.

Why are Latinos the most uninsured racial/ethnic group of US children? A community-based study of risk factors for and consequences of being an uninsured Latino child

BACKGROUND

Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children.

OBJECTIVE

[corrected] The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children.

METHODS

A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance.

RESULTS

Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers.

CONCLUSIONS

After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

Maternal and child factors affecting high-volume pediatric emergency department use

OBJECTIVE

To describe maternal and child characteristics associated with high-volume nonurgent pediatric emergency department (ED) use.

METHODS

We surveyed female caregivers of children aged 1 to 14 years who were brought to the ED at an urban medical center for nonurgent conditions. We analyzed characteristics associated with low-volume (1 ED visit) or high-volume (> or = 2 ED visits) use within the past year. Independent factors included predisposing, reinforcing, and enabling factors. Logistic regression was used to model high-volume ED use.

RESULTS

Of the 300 participants (84% response rate), 99 were low-volume users and 201 were high-volume users. Most participants were mothers (94%). In adjusted analyses, high-volume use was associated with caregivers being single [odds ratio (OR), 2.57; 95% confidence interval (CI), 1.13-5.80], having high-volume ED use for themselves (OR, 2.02; 95% CI, 1.08-3.80), seeking care primarily in the pediatric ED for "sick visits" (OR, 2.47; 95% CI, 1.12-5.49), and lack of weekend hours at their child's usual source of care (OR, 2.58; CI, 1.24-5.37).

CONCLUSIONS

Marital status, high maternal use of the ED, perception of the ED as the place to seek care for a sick child, and lack of weekend hours for usual source of care are associated with high-volume ED use among children. Given similarities in patterns of ED use among mothers and children, further attention is needed to address clinical practice and system issues that contribute to familial use of EDs.

Disparities for Latino Children in the Timely Receipt of Medical Care

OBJECTIVE

It is not known whether Latino children, the largest minority population in the United States, experience disparities in the timeliness of their access to health care. We compared timeliness of care among Latino, white, and African American children.

METHODS

DESIGN

cross-sectional cohort from the 2000 Medical Expenditure Panel Survey.

PATIENTS

children with a usual source of care.

OUTCOME MEASURE

timeliness of care was assessed using parent reports of their child's 1) routine care, 2) illness care, 3) phone help, and 4) experiencing of a brief wait time.

ANALYSIS

multiple logistic regression was used to determine the adjusted odds of not always receiving timely medical care.

RESULTS

Four-thousand one-hundred twenty children were included. Latino children were less likely to always (P < .05) receive timely care compared with whites and African Americans, respectively, in 3 areas: routine care, phone help, and brief wait time. Multiple regression revealed decreased relative risks (RR, 95% CI) of always receiving timely medical care for Latinos in the same areas: routine care, compared with whites (0.88, 0.79-0.98) and African Americans (0.81, 0.70-0.93); phone help, compared with whites (0.84, 0.76-0.92) and African Americans (0.86, 0.76-0.960); and brief wait time, compared with whites (0.71, 0.65-0.80) and African Americans (0.81, 0.70-0.92). With parental survey language in the model, Latinos experienced decreased timeliness of care for routine care compared with African Americans (0.85, 0.72-0.98); phone help compared with whites (0.87, 0.77-0.96); and brief wait times compared with whites (0.79, 0.71-0.87).

CONCLUSIONS

Latino children experience marked disparities in obtaining timely medical care, only some of which is associated with language differences.

Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study

STUDY OBJECTIVE

We determined whether having a usual source of care or health insurance is associated with the likelihood of an emergency department (ED) visit.

METHODS

This was a multivariate analysis of the 2000 to 2001 nationally representative Community Tracking Study Household Survey to assess the independent association of usual source of care, health insurance, income, and health status with the likelihood of making 1 or more ED visits in the previous year.

RESULTS

Based on a sample of 49,603 adults, an estimated 45.3 million adults reported 79.6 million ED visits in the previous year; 83.1% of these visitors identified a usual source of care other than an ED. Persons with poor physical health status made 48.4% of visits. Adults without a usual source of care were less likely to have had an ED visit than those whose usual source of care was a private physician (odds ratio [OR] 0.75). Uninsured individuals were no more likely to have an ED visit than insured individuals. Poor physical health (OR 2.41), poor mental health (OR 1.51), 5 or more outpatient visits during the year (OR 4.05), and changes in insurance coverage (OR 1.14) or usual source of care (OR 1.32) during the year were associated with an ED visit. Enrollment in a health maintenance organization and satisfaction with one's physician were not independently associated with ED use.

CONCLUSION

ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. The success of efforts to decrease ED use may depend on improving delivery of outpatient care.

Emergency department use among Michigan children with special health care needs: an introductory study

OBJECTIVE

To describe patterns of emergency department (ED) use among children dual-enrolled in Medicaid and Michigan's Children's Special Health Care Services (CSHCS).

DATA SOURCES

Individual claims and enrollment data from Michigan's Medicaid and CSHCS programs for the period January 1, 1998, to June 30, 1999. Claims data were linked with eligibility data and then used to develop a 100 percent sample of claims for individuals enrolled in both Medicaid and CSHCS.

STUDY DESIGN

Poisson regression analysis was used to examine the rate of ED use for dual-enrolled children. A time-varying hazard analysis was also used to examine the impact of changes over time. The key variables were gender, age, race, county of residence, Medicaid eligibility category, and qualifying diagnosis.

PRINCIPAL FINDINGS

Dual-enrolled children under one year of age, and those with qualifying diagnoses of anemia, hemophilia, asthma, epilepsy, and juvenile diabetes displayed especially high rates of ED use. Significant geographic variation in ED use remained after controlling for qualifying diagnoses, race/ethnicity, and other factors. African Americans displayed higher rates of ED utilization than non-Hispanic whites. Supplemental Security Income (SSI) recipients demonstrated higher utilization than other groups.

CONCLUSIONS

Children dually enrolled in CSHCS and Medicaid face diverse challenges of both poverty and chronic illness. Differences in patterns of use highlight the importance, but also the difficulty, of developing systems of care to manage complex chronic conditions in low-income populations.

A conceptual model of emergency department crowding

Emergency department (ED) crowding has become a major barrier to receiving timely emergency care in the United States. Despite widespread recognition of the problem, the research and policy agendas needed to understand and address ED crowding are just beginning to unfold. We present a conceptual model of ED crowding to help researchers, administrators, and policymakers understand its causes and develop potential solutions. The conceptual model partitions ED crowding into 3 interdependent components: input, throughput, and output. These components exist within an acute care system that is characterized by the delivery of unscheduled care. The goal of the conceptual model is to provide a practical framework on which an organized research, policy, and operations management agenda can be based to alleviate ED crowding.

The district hospital emergency department: Why do parents present?

OBJECTIVE

To identify parental reasons for presenting their child to the emergency department and their expectations of the consultation.

METHOD

Cross-sectional survey of parents of children and adolescents aged 14 years and under who presented to the Fairfield Emergency Department over a 2-month period.

RESULTS

A questionnaire was returned from 694 of 839 eligible presentations (83%), with 51% having an urgent triage and 26% being admitted. Proximity was nominated as the reason for choosing the Fairfield Emergency Department by 48%, 62% of presentations were self-referred and 44% had already seen another doctor. An urgent triage was associated with parental expectation of admission or observation in the emergency department (OR 2.79 [95% CI: 1.98-3.94]).

CONCLUSIONS

The majority of presentations to the district emergency department are self-referred and it is chosen because of proximity. The majority of children do not require admission; however, parents often have expectations that observation and further investigation will occur prior to discharge from the emergency department.

When the visit to the emergency department is medically nonurgent: provider ideologies and patient advice

It is estimated that more than half of pediatric hospital emergency department (ED) visits are medically nonurgent. Anecdotal impressions suggest that ED providers castigate medically nonurgent visits, yet studies on such visits are scarce. This study explored the perspectives of 26 providers working in the EDs of two urban hospitals regarding medically nonurgent pediatric ED visits and advising parents or guardians on appropriate ED use. Three provider ideologies regarding the appropriateness of medically nonurgent ED use were identified and found to be linked to particular communication strategies that providers employed with ED users: restrictive, pragmatic, and all-inclusive. The analysis resulted in the development of a typology of provider ideological orientations toward ED use, distinguished according to different orientations toward professional dominance.

Parental use of a paediatric emergency department as an ambulatory care service

OBJECTIVE

This qualitative study explored the parental attitudes, perceptions and beliefs that play a role in the use of a tertiary paediatric emergency department (PED) when a child has a non-urgent illness.

METHOD

Semi-structured, in-depth interviews of 25 parents of children with non-urgent illnesses were conducted in the waiting room of a tertiary PED in Western Sydney in 1998. Inductive analysis was used to identify dominant themes.

RESULTS

Parents used their own system of triage to choose the appropriate service for their sick child. The perceived expertise of the tertiary PED, access and parental expectations all appeared to be major factors in parental use of a PED.

CONCLUSIONS

The parental choice to attend a PED is a dynamic, complex and unique process and the parental views that underpin this process often diverge from those of health professionals about the most 'appropriate' use of a PED.

IMPLICATIONS

A clearer understanding by health professionals of the factors influencing parental choice will promote more effective collaboration with parents and ultimately assist in the decision on the best management option for sick children.