Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits

Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies

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.

Pediatric ED Utilization in a Destination City: Demographic, Clinical, and Temporal Trends

OBJECTIVES

Seasonal variation in emergency department (ED) visits has been shown for a variety of pediatric conditions, but previous studies have not considered how geographic location may also influence when and why these patients present to the ED. Our study examined the demographic and clinical characteristics as well as the seasonal variation among 3 patient populations (locals, in-state nonlocals, and out-of-state visitors) presenting to our pediatric ED (PED), which is located in a coastal, destination city.

METHODS

This was a retrospective chart review of PED visits from June 2014 to June 2019 at the Medical University of South Carolina Children's Hospital, a tertiary care facility located in Charleston, SC. Pediatric ED encounters were divided into 3 groups, depending on the patient's home address: local patients residing in the 3 surrounding metro counties, in-state but nonlocal patients, and out-of-state patients. Demographic and clinical information was abstracted for each visit and compared among the 3 patient groups. Seasonal variation among PED visits was determined by recording the week of the year during which each visit occurred.

RESULTS

Local patients accounted for more than 90% of PED visits with increases in visits from October to April. In-state nonlocal patients presented at consistent rates throughout the year, whereas out-of-state ED utilization peaked significantly during the summer months, Spring Break, Thanksgiving, and Christmas. Our local patient population was majority African American; our in-state nonlocal patients roughly matched our state's racial demographics, and our out-of-state population was predominantly White. Compared with in-state nonlocal patients, our local patients were more likely to present with an infection-related complaint and be diagnosed with lower-acuity conditions such as viral infection, otitis media, upper respiratory infection, cough, fever, and gastroenteritis. In-state nonlocal patients had the highest average triage acuity, more frequently had laboratory tests and imaging ordered, and were more than 4.5 times as likely to be admitted to the hospital compared with our local patients. In-state nonlocal patients were also more likely to present with a psychiatric chief complaint compared with our local patients. Out-of-state patients had a similar overall acuity to local patients but were more likely to have imaging ordered and be diagnosed with injuries such as fractures.

CONCLUSION

At our institution, local patients, in-state nonlocal patients, and out-of-state patients exhibited 3 distinct patterns of PED utilization. Knowledge of these trends can be used to optimize resource allocation and follow-up planning, particularly for our out-of-state patient population.

High-Frequency Utilization of the PICU

OBJECTIVES

To describe the demographic, clinical, outcome, and cost differences between children with high-frequency PICU admission and those without.

DESIGN

Retrospective, cross-sectional cohort study.

SETTING

United States.

PATIENTS

Children less than or equal to 18 years old admitted to PICUs participating in the Pediatric Health Information System database in 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed survivors of PICU admissions for repeat PICU admissions within a year of their index visit. Children with greater than or equal to 3 PICU admissions within a year were classified as high-frequency PICU utilization (HFPICU). We compared demographic, clinical, outcome, and cost characteristics between children with HFPICU and those with only an index or two admissions per year (nHFPICU). Of 95,465 children who survived an index admission, 5,880 (6.2%) met HFPICU criteria. HFPICU patients were more frequently younger, technology dependent, and publicly insured. HFPICU patients had longer lengths of stay and were more frequently discharged to a rehabilitation facility or with home nursing services. HFPICU patients accounted for 24.8% of annual hospital utilization costs among patients requiring PICU admission. Time to readmission for children with HFPICU was 58% sooner (95% CI, 56-59%) than in those with nHFPICU with two admissions using an accelerated failure time model. Among demographic and clinical factors that were associated with development of HFPICU status calculated from a multivariable analysis, the greatest effect size was for time to first readmission within 82 days.

CONCLUSIONS

Children identified as having HFPICU account for 6.2% of children surviving an index ICU admission. They are a high-risk patient population with increased medical resource utilization during index and subsequent ICU admissions. Patients readmitted within 82 days of discharge should be considered at higher risk of HFPICU status. Further research, including validation and exploration of interventions that may be of use in this patient population, are necessary.