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Amjad S, Tromburg C, Adesunkanmi M, Mawa J, Mahbub N, Campbell S, Chari R, Rowe BH, Ospina MB. Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies. Ann Emerg Med 2024; 83:291-313. [PMID: 38069966 DOI: 10.1016/j.annemergmed.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 03/24/2024]
Abstract
STUDY OBJECTIVE Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations. METHODS This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses. RESULTS Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission. CONCLUSION Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.
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Affiliation(s)
- Sana Amjad
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Courtney Tromburg
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Maryam Adesunkanmi
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Jannatul Mawa
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Nazif Mahbub
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Sandra Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Radha Chari
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maria B Ospina
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada; Department of Public Health Sciences, Queen's University; Kingston, Ontario, Canada.
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Structural racism is associated with adverse postnatal outcomes among Black preterm infants. Pediatr Res 2022:10.1038/s41390-022-02445-6. [PMID: 36577795 PMCID: PMC9795138 DOI: 10.1038/s41390-022-02445-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/03/2022] [Accepted: 11/28/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Structural racism contributes to racial disparities in adverse perinatal outcomes. We sought to determine if structural racism is associated with adverse outcomes among Black preterm infants postnatally. METHODS Observational cohort study of 13,321 Black birthing people who delivered preterm (gestational age 22-36 weeks) in California in 2011-2017 using a statewide birth cohort database and the American Community Survey. Racial and income segregation was quantified by the Index of Concentration at the Extremes (ICE) scores. Multivariable generalized estimating equations regression models were fit to test the association between ICE scores and adverse postnatal outcomes: frequent acute care visits, readmissions, and pre- and post-discharge death, adjusting for infant and birthing person characteristics and social factors. RESULTS Black birthing people who delivered preterm in the least privileged ICE tertiles were more likely to have infants who experienced frequent acute care visits (crude risk ratio [cRR] 1.3 95% CI 1.2-1.4), readmissions (cRR 1.1 95% CI 1.0-1.2), and post-discharge death (cRR 1.9 95% CI 1.2-3.1) in their first year compared to those in the privileged tertile. Results did not differ significantly after adjusting for infant or birthing person characteristics. CONCLUSION Structural racism contributes to adverse outcomes for Black preterm infants after hospital discharge. IMPACT STATEMENT Structural racism, measured by racial and income segregation, was associated with adverse postnatal outcomes among Black preterm infants including frequent acute care visits, rehospitalizations, and death after hospital discharge. This study extends our understanding of the impact of structural racism on the health of Black preterm infants beyond the perinatal period and provides reinforcement to the concept of structural racism contributing to racial disparities in poor postnatal outcomes for preterm infants. Identifying structural racism as a primary cause of racial disparities in the postnatal period is necessary to prioritize and implement appropriate structural interventions to improve outcomes.
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Abstract
Significant racial and ethnic disparities exist in birth outcomes and complications related to prematurity. However, little is known about racial and ethnic variations in health outcomes after premature infants are discharged from the neonatal intensive care unit (NICU). We propose a novel, equity-focused conceptual model to guide future evaluations of post-discharge outcomes that centers on a multi-dimensional, comprehensive view of health, which we call thriving. We then apply this model to existing literature on post-discharge inequities, revealing a need for rigorous analysis of drivers and strength-based, longitudinal outcomes.
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Affiliation(s)
- Daria C Murosko
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia PA.
| | - Michelle-Marie Peña
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia PA; Department of Pediatrics, Division of Neonatology, Emory University School of Medicine and Children's Healthcare of Atlanta
| | - Scott A Lorch
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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Kappy B, Edmunds K, Frey M, Zhang Y, Boyd S, Looman K, Pomerantz WJ, Hanke S, Kerrey B. Emergency Department Visits Before Sudden Unexpected Infant Death: A Touchpoint for Unsafe Sleep Reduction. Acad Pediatr 2022; 22:1065-1072. [PMID: 35307602 DOI: 10.1016/j.acap.2022.03.009] [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: 12/21/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death. METHODS We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID. RESULTS Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3. CONCLUSIONS Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts.
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Affiliation(s)
- Brandon Kappy
- Division of Emergency Medicine (B Kappy, K Edmunds, M Frey, Y Zhang, S Boyd, WJ Pomerantz, and B Kerrey), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Katherine Edmunds
- Division of Emergency Medicine (B Kappy, K Edmunds, M Frey, Y Zhang, S Boyd, WJ Pomerantz, and B Kerrey), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics (K Edmunds, WJ Pomerantz, B Kerrey and S Hanke), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mary Frey
- Division of Emergency Medicine (B Kappy, K Edmunds, M Frey, Y Zhang, S Boyd, WJ Pomerantz, and B Kerrey), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yin Zhang
- Division of Emergency Medicine (B Kappy, K Edmunds, M Frey, Y Zhang, S Boyd, WJ Pomerantz, and B Kerrey), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephanie Boyd
- Division of Emergency Medicine (B Kappy, K Edmunds, M Frey, Y Zhang, S Boyd, WJ Pomerantz, and B Kerrey), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karen Looman
- Hamilton County Coroner's Office (K Looman), Cincinnati, Ohio; Department of Pathology and Laboratory Medicine (K Looman), University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Wendy J Pomerantz
- Division of Emergency Medicine (B Kappy, K Edmunds, M Frey, Y Zhang, S Boyd, WJ Pomerantz, and B Kerrey), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics (K Edmunds, WJ Pomerantz, B Kerrey and S Hanke), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Samuel Hanke
- Department of Pediatrics (K Edmunds, WJ Pomerantz, B Kerrey and S Hanke), University of Cincinnati College of Medicine, Cincinnati, Ohio; Heart Institute, Cincinnati Children's Hospital Medical Center (S Hanke), Cincinnati, Ohio
| | - Benjamin Kerrey
- Division of Emergency Medicine (B Kappy, K Edmunds, M Frey, Y Zhang, S Boyd, WJ Pomerantz, and B Kerrey), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics (K Edmunds, WJ Pomerantz, B Kerrey and S Hanke), University of Cincinnati College of Medicine, Cincinnati, Ohio
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Anyatonwu SC, Giannouchos TV, Washburn DJ, Quinonez RA, Ohsfeldt RL, Kum HC. Predictors of Pediatric Frequent Emergency Department Use Among 7.6 million Pediatric Patients in New York. Acad Pediatr 2022; 22:1073-1080. [PMID: 35385791 DOI: 10.1016/j.acap.2022.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study examines the characteristics and factors associated with frequent emergency department (ED) utilization among the pediatric population. METHODS We conducted a pooled cross-sectional secondary analysis using the Healthcare Cost and Utilization Project State Emergency and Inpatient Databases on ED visits to all hospitals in New York from 2011 to 2016 by patients aged 0 to 21. We used multivariable logistic and negative binomial regressions to investigate the predictors of multiple ED visits in the pediatric population. RESULTS Overall, our study included 7.6 million pediatric patients who accounted for more than 12 million ED visits. Of those, 6.2% of patients were frequent ED users (≥4 visits/year), accounting for 20.8% of all ED visits (5.4 ED visits/year on average). The strongest predictors of frequent ED use were having at least one ED visit related to asthma (aOR = 8.37 [95% CI: 6.34-11.04]), mental health disorders (aOR = 9.67 [95% CI: 8.60-10.89]), or multiple comorbidities compared to none. Larger shares of ED visits for not-emergent conditions were also associated with frequent ED use (aOR = 6.63 [95% CI = 5.08-8.65]). Being covered by Medicaid compared to private (aOR = 0.45 [95% CI: 0.42-0.47]) or no insurance (aOR = 0.41 [95% CI: 0.38-0.44]) were further associated with frequent ED use. The results from the negative binomial regression yielded consistent findings. CONCLUSIONS Pediatric patients who exhibit increased ED use are more medically complex and have increased healthcare needs that are inextricably tied to social determinants of health. Better integrated health systems should emphasize connecting vulnerable patients to appropriate social and primary care services outside of emergency settings.
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Affiliation(s)
- Sophia C Anyatonwu
- Population Informatics Lab, School of Public Health (SC Anyatonwu, TV Giannouchos, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex; Department of Health Policy & Management, School of Public Health (SC Anyatonwu, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex
| | - Theodoros V Giannouchos
- Population Informatics Lab, School of Public Health (SC Anyatonwu, TV Giannouchos, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex; Department of Health Services Policy & Management, Arnold School of Public Health (TV Giannouchos), University of South Carolina, Columbia, SC.
| | - David J Washburn
- Population Informatics Lab, School of Public Health (SC Anyatonwu, TV Giannouchos, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex; Department of Health Policy & Management, School of Public Health (SC Anyatonwu, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex
| | - Ricardo A Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine (RA Quinonez), Texas Children's Hospital, Houston, Tex
| | - Robert L Ohsfeldt
- Population Informatics Lab, School of Public Health (SC Anyatonwu, TV Giannouchos, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex; Department of Health Policy & Management, School of Public Health (SC Anyatonwu, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex
| | - Hye-Chung Kum
- Population Informatics Lab, School of Public Health (SC Anyatonwu, TV Giannouchos, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex; Department of Health Policy & Management, School of Public Health (SC Anyatonwu, DJ Washburn, RL Ohsfeldt, and HC Kum), Texas A&M University, College Station, Tex
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Rosychuk RJ, Chen AA, McRae A, McLane P, Ospina MB, Hu XIJ. Age-varying effects of repeated emergency department presentations for children in Canada. J Health Serv Res Policy 2022; 27:278-286. [PMID: 35521743 PMCID: PMC9548929 DOI: 10.1177/13558196221094248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objectives Repeated presentations to emergency departments (EDs) may indicate a lack of
access to other health care resources. Age is an important predictor of
frequent ED use; however, age-varying effects are not generally
investigated. This study examines the age-specific effects of predictors on
ED presentation frequency for children in Alberta and Ontario, Canada. Methods This retrospective study used population-based data during April 2010 to
March 2017. Data were extracted from the National Ambulatory Care Reporting
System for children aged <18 who were members of the top 10% of ED users
in any one of the fiscal years 2011/2012 to 2015/2016 along with a
comparison sample from the bottom 90%. A marginal regression model studied
the age-varying associations on the frequency of ED presentations with
province, sex, access to primary health care provider (for Ontario only),
area of residence and lowest neighbourhood income quintile. Results There were 2,481,172 patients who made 9,229,156 ED presentations. The
effects of sex, lowest income quintile, rural residence, access to primary
health care provider and province on the frequency of presentations varied
by age. Notably, boys go from having more frequent presentations than girls
when aged ≤5 (i.e. adjusted intensity ratio [IR]=1.04 at age 5, 95%
confidence interval [CI] = 1.03,1.06) to less frequent for ages 8–11 years
and beyond 14 (i.e. IR = 0.80 at age 15, 95% CI = 0.78,0.81). Adolescents
aged ≥15 without access to a primary care provider had more frequent
presentations compared to those with a primary care provider. Conclusions When examining the frequency of ED presentations in children, age-varying
effects of predictors should be considered. Our more nuanced examination of
age provides insights into how health services might better target
programmes for different ages to potentially reduce unnecessary ED use by
providing other health care alternatives.
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Affiliation(s)
- Rhonda J Rosychuk
- Department of Pediatrics, 3158University of Alberta, Edmonton, AB, Canada
| | - Anqi A Chen
- Department of Statistics and Actuarial Science, 1763Simon Fraser University, Burnaby, BC, Canada
| | - Andrew McRae
- Department of Emergency Medicine, 2129University of Calgary, Calgary, AB, Canada
| | - Patrick McLane
- Emergency Strategic Clinical Network, 3146Alberta Health Services, Edmonton, Canada
| | - Maria B Ospina
- Department of Pediatrics, 3158University of Alberta, Edmonton, AB, Canada
| | - X Iaoqiong Joan Hu
- Department of Statistics and Actuarial Science, 1763Simon Fraser University, Burnaby, BC, Canada
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Rosychuk RJ, Chen A, McRae A, McLane P, Ospina MB, Stang AS. Characteristics of Pediatric Frequent Users of Emergency Departments in Alberta and Ontario. Pediatr Emerg Care 2022; 38:108-114. [PMID: 34772876 DOI: 10.1097/pec.0000000000002569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Emergency department (ED) volumes have drawn attention to frequent users but less attention has been paid to children. This study examined sociodemographic and ED presentation characteristics of pediatric high-system ED users (HSUs) in 2 provinces in Canada. METHODS Cohorts of HSUs were created from the National Ambulatory Care Reporting System in 2015/2016 for children with the top 10% of ED presentations. Controls were random samples of non-HSU patients. Factors were explored in multivariable logistic regression models. RESULTS There were 151,497 HSUs (51.7% girls, average age, 6.4 years) and 591,545 controls (53.1% girls; average age, 7.4 years). High-system ED users were more likely to be younger (adjusted odds ratio [aOR], 0.89 per 5 years; 95% confidence interval [CI], 0.88-0.89), live in less populated areas (aOR, 1.85; 95% CI, 1.82-1.88), and from lowest income neighborhoods (aOR, 1.51; 95% CI, 1.48-1.54) than controls. High-system ED users had higher proportions of presentations for pediatric complex chronic (aOR, 1.25 per 0.25 increase; 95% CI, 1.21-1.29), respiratory (aOR, 1.14 per 0.25; 95% CI, 1.12-1.15), and mental health (aOR, 1.14 per 0.25; 95% CI, 1.13-1.16) conditions than controls. CONCLUSIONS Complex factors underlie pediatric health care utilization decisions. Findings identified conditions to target in interventions to improve health care access and utilization. Future work should engage children and families to design interventions.
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Michelson KA, Cushing AM, Bucholz EM. Association of County-Level Availability of Pediatricians With Emergency Department Visits. Pediatr Emerg Care 2022; 38:e953-e957. [PMID: 34282091 PMCID: PMC8770659 DOI: 10.1097/pec.0000000000002502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The relationship between pediatrician availability and emergency department (ED) attendance is uncertain. We determined whether children in counties with more pediatricians had fewer ED visits. METHODS We conducted a cross-sectional study of all ED visits among children younger than 18 years from 6 states. We obtained ED visit incidences by county and assessed the relationship to pediatrician density (pediatricians per 1000 children). Possible confounders included state, presence of an urgent care facility in the county, urban-rural status, and quartile of county-level characteristics: English-speaking, Internet access, White race, socioeconomic status, and public insurance. We estimated county-level changes in incidence by pediatrician density adjusting for state and separately for all possible confounders. RESULTS Each additional pediatrician per 1000 children was associated with a 13.7% (95% confidence interval, -19.6% to -7.5%) decrease in ED visits in the state-adjusted model. In the full model, there was no association (-1.4%, 95% confidence interval, -7.2% to 4.8%). The presence of an urgent care, higher socioeconomic status score, urban status, and higher proportions of White race and nonpublic insurance were each associated with decreased ED visit rates. CONCLUSIONS Pediatrician density is not associated with decreased ED visits after adjusting for other county demographic factors. Increasing an area's availability of pediatricians may not affect ED attendance.
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Affiliation(s)
| | - Anna M Cushing
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Emily M Bucholz
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA
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Sojar S, Gjelsvik A, Tsao HS, Amanullah S. Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment. Pediatr Emerg Care 2022; 38:e569-e574. [PMID: 33635045 DOI: 10.1097/pec.0000000000002319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States. METHODS The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health. RESULTS Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits. CONCLUSIONS Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.
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Okeson K, Reid C, Mashayekh S, Sonu S, Moran TP, Agarwal M. Adverse Childhood Experiences and Healthcare Utilization of Children in Pediatric Emergency Departments. J Pediatr 2022; 240:206-212. [PMID: 34547336 DOI: 10.1016/j.jpeds.2021.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/05/2021] [Accepted: 09/10/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the prevalence of adverse childhood experiences (ACEs) and healthcare utilization patterns of children seen in pediatric emergency departments (PEDs). STUDY DESIGN In this cross-sectional study, caregivers of patients who presented to 2 urban PEDs completed a survey regarding their children's ACEs, health care utilization patterns, and acceptance of PED-based ACEs screening and resources. Inclusion criteria were English-speaking caregivers of patients 0-17 years of age not requiring acute stabilization. Prevalence estimates were compared with national and state data from the National Survey of Children's Health by calculating risk differences and 95% CIs. The association of cumulative ACEs with caregiver-reported health care utilization patterns was evaluated using ORs. RESULTS Among 1000 participants, 28.1% (95% CI 25.3-30.9) had 1 ACE; 17.8% (95% CI15.4-20.2) had ≥2 ACEs. Notably, children with higher cumulative ACEs were seen in the PED more frequently (0, 1, ≥2 visits) (OR 1.18, 95% CI 1.06-1.30, P = .002) and more likely to seek care in PEDs for sick visits (OR 1.16, 95% CI 1.04-1.30, P = .01). About 9% of children exposed to ACEs did not have a primary care provider. Over 85% of caregivers reported never discussing ACEs with their primary care provider. Most caregivers felt comfortable addressing ACEs in PEDs (84.4%) and would use referral resources (90.4%). CONCLUSIONS Given higher PED utilization in children with more ACEs and caregiver acceptance of PED-based screening and intervention, PEDs may represent a strategic and opportune setting to both assess and respond to ACEs among vulnerable populations.
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Affiliation(s)
- Karli Okeson
- Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.
| | - Carmen Reid
- Emory University School of Medicine, Atlanta, GA
| | | | - Stan Sonu
- Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
| | - Maneesha Agarwal
- Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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Vivier PM, Rogers ML, Gjelsvik A, Linakis JG, Schlichting LE, Mello MJ. Frequent Emergency Department Use by Children. Pediatr Emerg Care 2021; 37:e995-e1000. [PMID: 31305503 DOI: 10.1097/pec.0000000000001859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization. METHODS The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics. RESULTS Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency. CONCLUSIONS Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.
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Greenfield G, Okoli O, Quezada-Yamamoto H, Blair M, Saxena S, Majeed A, Hayhoe B. Characteristics of frequently attending children in hospital emergency departments: a systematic review. BMJ Open 2021; 11:e051409. [PMID: 34663662 PMCID: PMC8523960 DOI: 10.1136/bmjopen-2021-051409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To summarise the literature on frequent attendances to hospital emergency departments (EDs) and describe sociodemographic and clinical characteristics of children who attend EDs frequently. SETTING Hospital EDs. PARTICIPANTS Children <21 years, attending hospital EDs frequently. PRIMARY OUTCOME MEASURES Outcomes measures were defined separately in each study, and were predominantly the number of ED attendances per year. RESULTS We included 21 studies representing 6 513 627 children. Between 0.3% and 75% of all paediatric ED users were frequent users. Most studies defined four or more visits per year as a 'frequent ED' usage. Children who were frequent ED users were more likely to be less than 5 years old. In the USA, patients with public insurance were more likely to be frequent attenders. Frequent ED users more likely to be frequent users of primary care and have long-term conditions; the most common diagnoses were infections and gastroenteritis. CONCLUSIONS The review included a wide range of information across various health systems, however, children who were frequent ED users have some universal characteristics in common. Policies to reduce frequent attendance might usefully focus on preschool children and supporting primary care in responding to primary care oriented conditions.
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Affiliation(s)
- Geva Greenfield
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Olivia Okoli
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Harumi Quezada-Yamamoto
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Mitch Blair
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Benedict Hayhoe
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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13
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Brief report: Acute care visits vary by race and ethnicity among publicly insured preterm infants. Pediatr Res 2021; 90:712-716. [PMID: 33958716 DOI: 10.1038/s41390-021-01504-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/18/2021] [Accepted: 03/16/2021] [Indexed: 01/30/2023]
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Guyon-Harris KL, Bogen DL, Huth-Bocks AC. Maternal Psychological Well-Being and Infant Emergency Department Utilization. Acad Pediatr 2021; 21:885-891. [PMID: 33548524 DOI: 10.1016/j.acap.2021.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/22/2021] [Accepted: 01/30/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND A mother's psychological well-being impacts her own and her infant's health. Challenges to maternal psychological well-being (eg, depression, anxiety) are associated with increased infant emergency department (ED) utilization. It is not known if other maternal psychological factors, such as relational health and past maltreatment during one's own childhood, are also associated with child ED utilization. OBJECTIVE Examine maternal psychological factors (ie, childhood maltreatment, mental health, and relational health) associated with infant ED utilization in the first year of life. DESIGN/METHODS Participants included 120 economically disadvantaged women recruited into a prospective longitudinal study during pregnancy and followed across the first year of their child's life. Mothers reported number of infant ED visits from birth to 1 year (assessed 12-months postpartum), as well as on their own childhood maltreatment, relational health, and mental health (assessed prenatally). Associations between maternal experiences and infant ED utilization were assessed via bivariate correlations and regression analyses. RESULTS Infants attended on average 0.79 ED visits (range 0-6). Maltreatment during the mother's own childhood, poor relational health, and prenatal mental health symptoms were each associated with greater infant ED visits; maternal age, income, and education were not. In a Poisson regression, childhood sexual abuse was the strongest predictor of infant ED utilization, followed by low acceptance from the mother's father figure and prenatal depression. CONCLUSIONS Prenatal assessment of psychosocial factors may help identify risk for higher ED use. Women with psychosocial risk factors may need additional support establishing supportive primary and behavioral health care before and after birth.
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Affiliation(s)
- Katherine L Guyon-Harris
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine (KL Guyon-Harris), Pittsburgh, Pa.
| | - Debra L Bogen
- Allegheny County Health Department (DL Bogen), Pittsburgh, Pa
| | - Alissa C Huth-Bocks
- Department of Pediatrics, Developmental-Behavioral Pediatrics & Psychology, Rainbow Babies & Children's Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine (AC Huth-Bocks), Cleveland, Ohio
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15
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Giannouchos TV, Washburn DJ, Gary JC, Foster MJ. Frequent emergency department use in the paediatric population: A systematic literature review. J Eval Clin Pract 2021; 27:193-203. [PMID: 32141125 DOI: 10.1111/jep.13382] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We systematically reviewed the literature on paediatric frequent emergency department (ED) users to identify and to synthesize characteristics and factors associated with frequent ED utilization among this population in the United States. METHODS We searched Medline (Ovid), CINAHL (Ebsco), and Embase (Ovid) to identify all relevant studies after 1990. We focused on US studies analysing paediatric frequent ED (PFED) users excluding those focused on specific subgroups. Two reviewers independently selected articles and extracted data on predisposing, enabling, behavioural, need and reinforcing factors. RESULTS Fifteen studies met the inclusion criteria. PFED users comprised 3% to 14% of all paediatric ED users and accounted for 9% to 42% of all paediatric ED visits in 11 studies that defined frequent use as four to six ED visits per year. Most PFED users were less than 5 years old who had public insurance coverage and a regular provider. Public insurance compared to private residency in disadvantaged areas, having at least one chronic or complex condition and a history of hospitalization, were associated with frequent use. Children who had a regular primary care provider were less likely to exhibit frequent ED use. CONCLUSIONS Minimizing unnecessary ED visits by frequent utilizers is a quality improvement and cost-saving priority for health systems. Our findings indicate that many PFED users have greater healthcare needs and face barriers accessing care in a timely manner, even though some have regular providers. To better address the needs of this vulnerable group, health systems should focus on educating caregivers and expanding access to providers in other settings.
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Affiliation(s)
- Theodoros V Giannouchos
- School of Public Health, Department of Health Policy and Management, Texas A&M University, College Station, Texas, USA.,Population Informatics Lab, Texas A&M University, College Station, Texas, USA
| | - David J Washburn
- School of Public Health, Department of Health Policy and Management, Texas A&M University, College Station, Texas, USA
| | - Jodie C Gary
- Health Science Center College of Nursing, Texas A&M University, Bryan, Texas, USA
| | - Margaret J Foster
- Medical Sciences Library, Texas A&M University, College Station, Texas, USA
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Chiu Y, Racine-Hemmings F, Dufour I, Vanasse A, Chouinard MC, Bisson M, Hudon C. Statistical tools used for analyses of frequent users of emergency department: a scoping review. BMJ Open 2019; 9:e027750. [PMID: 31129592 PMCID: PMC6537981 DOI: 10.1136/bmjopen-2018-027750] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user. METHODS We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis. RESULTS We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used. CONCLUSIONS This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.
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Affiliation(s)
- Yohann Chiu
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - François Racine-Hemmings
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Isabelle Dufour
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alain Vanasse
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Cabey WV, Shea JA, Kangovi S, Kennedy D, Onwuzulike C, Fein J. Understanding Pediatric Caretakers' Views on Obtaining Medical Care for Low-acuity Illness. Acad Emerg Med 2018; 25:1004-1013. [PMID: 29741232 DOI: 10.1111/acem.13436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 04/07/2018] [Accepted: 04/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND A significant proportion of low-acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low-acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers' perspectives. The objective of this study was to explore caretaker decision-making processes, values, and priorities when deciding to seek care. METHODS We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing. RESULTS Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision-making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low-acuity care was well received by caretakers. CONCLUSIONS Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low-acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.
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Affiliation(s)
| | - Judy A. Shea
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | - Shreya Kangovi
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | | | | | - Joel Fein
- Department of Pediatrics Perelman School of Medicine The Children's Hospital of Philadelphia Philadelphia PA
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18
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Schinasi LH, Auchincloss AH, Forrest CB, Diez Roux AV. Using electronic health record data for environmental and place based population health research: a systematic review. Ann Epidemiol 2018; 28:493-502. [PMID: 29628285 DOI: 10.1016/j.annepidem.2018.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/13/2018] [Accepted: 03/16/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE We conducted a systematic review of literature published on January 2000-May 2017 that spatially linked electronic health record (EHR) data with environmental information for population health research. METHODS We abstracted information on the environmental and health outcome variables and the methods and data sources used. RESULTS The automated search yielded 669 articles; 128 articles are included in the full review. The number of articles increased by publication year; the majority (80%) were from the United States, and the mean sample size was approximately 160,000. Most articles used cross-sectional (44%) or longitudinal (40%) designs. Common outcomes were health care utilization (32%), cardiometabolic conditions/obesity (23%), and asthma/respiratory conditions (10%). Common environmental variables were sociodemographic measures (42%), proximity to medical facilities (15%), and built environment and land use (13%). The most common spatial identifiers were administrative units (59%), such as census tracts. Residential addresses were also commonly used to assign point locations, or to calculate distances or buffer areas. CONCLUSIONS Future research should include more detailed descriptions of methods used to geocode addresses, focus on a broader array of health outcomes, and describe linkage methods. Studies should also explore using longitudinal residential address histories to evaluate associations between time-varying environmental variables and health outcomes.
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Affiliation(s)
- Leah H Schinasi
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA; Urban Health Collaborative, Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA.
| | - Amy H Auchincloss
- Urban Health Collaborative, Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA; Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | | | - Ana V Diez Roux
- Urban Health Collaborative, Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA; Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA
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Schlichting LE, Rogers ML, Gjelsvik A, Linakis JG, Vivier PM. Pediatric Emergency Department Utilization and Reliance by Insurance Coverage in the United States. Acad Emerg Med 2017; 24:1483-1490. [PMID: 28833943 DOI: 10.1111/acem.13281] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/09/2017] [Accepted: 08/15/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care. METHODS Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits. RESULTS A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51-0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47-1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49-2.42) were more likely to be reliant on the ED than children with private insurance. CONCLUSIONS Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.
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Affiliation(s)
| | | | - Annie Gjelsvik
- Hassenfeld Child Health Innovation Institute; Providence RI
- Department of Epidemiology; Providence RI
- Department of Pediatrics; Alpert Medical School; Providence RI
| | - James G. Linakis
- Hassenfeld Child Health Innovation Institute; Providence RI
- Department of Pediatrics; Alpert Medical School; Providence RI
- Department of Emergency Medicine; Alpert Medical School; Providence RI
- Injury Prevention Center; Rhode Island Hospital; Providence RI
| | - Patrick M. Vivier
- Hassenfeld Child Health Innovation Institute; Providence RI
- Department of Pediatrics; Alpert Medical School; Providence RI
- Department of Health Services, Policy, and Practice; Brown University; Providence RI
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20
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Peltz A, Samuels-Kalow ME, Rodean J, Hall M, Alpern ER, Aronson PL, Berry JG, Shaw KN, Morse RB, Freedman SB, Cohen E, Simon HK, Shah SS, Katsogridakis Y, Neuman MI. Characteristics of Children Enrolled in Medicaid With High-Frequency Emergency Department Use. Pediatrics 2017; 140:peds.2017-0962. [PMID: 28765381 PMCID: PMC5574719 DOI: 10.1542/peds.2017-0962] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years. METHODS Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use. RESULTS A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use. CONCLUSIONS One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.
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Affiliation(s)
- Alon Peltz
- Robert Wood Johnson Foundation Clinical Scholars Program and .,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | | | | | | | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Kathy N. Shaw
- Departments of Pediatrics and,Emergency Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rustin B. Morse
- Children’s Health System of Texas, and Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and,Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harold K. Simon
- Division of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia; and
| | - Samir S. Shah
- Divisions of Hospital Medicine and,Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark I. Neuman
- Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
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Abstract
OBJECTIVES Emergency department (ED) crowding is associated with increased morbidity and mortality. Its etiology is multifactorial, and frequent ED use (defined as more or equal to five visits per year) is a major contributor to high patient volumes. Our primary objective is to characterize the frequent user population. Our secondary objective is to examine risk factors for frequent emergency use. METHODS We conducted a retrospective cohort study of pediatric emergency department (PED) visits at the Montreal Children's Hospital using the Système Informatique Urgence (SIURGE), electronic medical record database. We analysed the relation between patient's characteristics and the number of PED visits over a 1-year period following the index visit. RESULTS Patients totalling 52,088 accounted for 94,155 visits. Of those, 2,474 (4.7%) patients had five and more recurrent visits and accounted for 16.6% (15,612 visits) of the total PED visits. Lower level of acuity at index visit (odds ratio [OR] 0.85) was associated with a lower number of recurrent visits. Lower socioeconomic status (social deprivation index OR 1.09, material deprivation index OR 1.08) was associated with a higher number of recurrent visits. Asthma (OR 1.57); infectious ear, nose, and sinus disorders (OR 1.33); and other respiratory disorders (OR 1.56) were independently associated with a higher incidence of a recurrent visit within the year following the first visit. CONCLUSION Our study is the first Canadian study to assess risk factors of frequent pediatric emergency use. The identified risk factors and diagnoses highlight the need for future evidence-based, targeted innovative research evaluating strategies to minimize ED crowding, to improve health outcomes and to improve patient satisfaction.
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Lindley LC, Trujillo LV. End-of-Life Care for Hispanic Children: A Study of California Medicaid Beneficiaries. HISPANIC HEALTH CARE INTERNATIONAL 2016; 14:164-169. [PMID: 27650201 PMCID: PMC5136309 DOI: 10.1177/1540415316670900] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION More than 8,000 Hispanic children die annually in the United States; yet little is known about the end-of-life care utilized. The purpose of this study was to examine the children and family characteristics associated with end-of-life care for Hispanic children. METHOD A sample of 370 Hispanic children was created, using the 2009-2010 California Medicaid data. The relationship between child and family characteristics and end-of-life care utilization (i.e., hospice enrollment, emergency room utilization, hospital admissions) was analyzed using multivariate regression. RESULTS Pediatric hospice accessibility (p < .05), palliative care policy (p < .01), congenital anomalies (p < .01), and cardiovascular conditions (p < .01) were related to hospice enrollment. Usual source of care (p < .001), functional status (p < .001), palliative care policy (p < .01), and private insurance (p < .01) were associated with emergency room utilization, while usual source of care (p < .001), cancer (p < .001), and disability status (p < .01) corresponded with hospital admissions. CONCLUSION Nursing practices aimed at engaging Hispanic families in their community are critical to end-of-life care utilization for Hispanic children.
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MacNeill EC, Cabey W, Kluge R, Norton J, Mitchell AM. Emergency Department Utilization in Children <36 Months Is Not an Independent Risk Factor for Maltreatment. Acad Emerg Med 2016; 23:1228-1234. [PMID: 27717129 DOI: 10.1111/acem.13100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 08/02/2016] [Accepted: 08/23/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Early childhood high-frequency use (HFU) of the emergency department (ED) has been endorsed as a marker for increased risk of child maltreatment. In a prior analysis of pediatric ED (PED) visits by 16,664 children, 0-36 months old, we defined early childhood HFU (the 90th percentile) as five or more visits. The purpose of this study was to follow HFU patients to determine if they had a higher likelihood of reported maltreatment. METHODS This is a single-center, cross-sectional, observational study of the association between PED use in early life and subsequent intervention by child protective services (CPS). CPS data were obtained from a Department of Social Services database for subjects meeting criteria for PED HFU as well as sex, race, and ethnicity-matched controls. Multivariable analyses were performed to assess if HFU was independently associated with child maltreatment. RESULTS While CPS involvement was more highly represented in the group with PED HFU, so were many confounding variables such as African American race, history of hospital admissions, and social work consultations in the PED for any reason. HFU, by itself, is not a risk factor for a major intervention by CPS. CONCLUSIONS In efforts to identify children at risk for maltreatment, objective assessments such as PED utilization are potential markers to utilize to aid in recognition. Unfortunately, there are many risk factors for increased PED utilization that act as confounders for this marker. Future work is necessary to identify children at risk for maltreatment in the ED.
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Affiliation(s)
| | - Whitney Cabey
- Carolinas Healthcare System; Charlotte NC
- Philadelphia Veterans Administration Medical Center; Philadelphia PA
- Robert Wood Johnson Clinical Scholars Program; The University of Pennsylvania; Philadelphia PA
| | - Robert Kluge
- Youth and Family Services; Mecklenburg County NC
| | | | - Alice M. Mitchell
- Carolinas Healthcare System; Charlotte NC
- Indiana University School of Medicine; Indianapolis IN
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Christensen EW, Kharbanda AB, Velden HV, Payne NR. Predicting Frequent Emergency Department Use by Pediatric Medicaid Patients. Popul Health Manag 2016; 20:208-215. [PMID: 27564725 DOI: 10.1089/pop.2016.0051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective of this study was to determine the patient characteristics and health care utilization patterns that predict frequent emergency department (ED) use (≥4 visits per year) over time to assist health care organizations in targeting patients for care management. This was a retrospective, population-based study of 13,265 Medicaid children aged 0-20 years who were attributed to a single pediatric accountable care organization for at least 2 consecutive years between June 2012 and May 2015. Year-to-year persistence as a frequent ED user was 36.3% (95% confidence interval [CI]: 33.4 to 38.4), which does not support the notion that once a frequent user, always a frequent user. Hence, interventions to reduce frequent ED use may appear to be effective when ED use would have regressed toward the mean without any intervention. At an individual patient level, predictability of frequent ED use was 0.437 (95% CI: 0.358 to 0.485) across frequent ED users of all ages compared with 0.723 (95% CI: 0.435 to 0.824) for those aged <1 year. Accordingly, this latter group may be a better target for interventions than frequent ED users generally.
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Affiliation(s)
- Eric W Christensen
- 1 Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
| | - Anupam B Kharbanda
- 2 Department of Critical Care and Emergency Medicine, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
| | - Heidi Vander Velden
- 1 Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
| | - Nathaniel R Payne
- 1 Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota , Minneapolis, Minnesota
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Does Nursery-Based Intensified Anticipatory Guidance Reduce Emergency Department Use for Nonurgent Conditions in the First Month of Life? A Randomized Controlled Trial. Int J Pediatr 2016; 2016:8356582. [PMID: 27212955 PMCID: PMC4860224 DOI: 10.1155/2016/8356582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/18/2016] [Accepted: 03/29/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. We aimed to evaluate the impact of an intensified anticipatory guidance program in the nursery on Emergency Department (ED) use for nonurgent conditions (NUCs) in the neonatal period. Methods. Parturient mothers of healthy newborns were randomized to an intervention group or control group. Baseline and 1-month follow-up knowledge surveys regarding newborn care were conducted. The primary outcome was the proportion of neonates who used the ED for a NUC. Secondary outcome was change in caregivers' knowledge on NUC. Results. Of a total of 594 mothers, 323 (54%) agreed to participate and were randomized to intervention (n = 170) or control (n = 153) group. Most were Hispanic (68%), single (61%), primiparous (39%), and without high school diploma (44%). 35 (21%) neonates in the intervention group and 41 (27%) in the control group were brought at least once for a NUC to the ED (p = 0.12). There was no statistically significant difference in within subject change on knowledge scores between the two study arms. Conclusions. Neonatal ED visits for NUCs occur frequently. This nursery-based intensified anticipatory guidance program had no statistically significant impact on neonatal ED use for NUC, nor on neonatal care-relevant knowledge among parturient mothers. Alternative modalities and timing of parental educational intervention may need to be considered. This trial is registered with Clinical Trials Number NCT01859065 (Clinicaltrials.gov).
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