Comparison of emergency care delivered to children and young adults with complex chronic conditions between pediatric and general emergency departments

Human-Centered Design to Create an Emergency Care Action Plan for Children With Medical Complexity

Human-centered design (HCD) is rooted in building trust with end users by developing empathetic understanding of key partners' needs, continuous engagement, and iterative solution creation and refinement. One of the core tenets of HCD in health care is that consistent end-user engagement will result in better health outcomes. Children with medical complexity (CMC), a subset of children and youth with special health care needs, are characterized by multiple chronic health care conditions and high health care use, including emergency department visits. To address the known challenges with providing high-quality care for CMC in emergency settings, emergency information forms are currently recommended to provide insights into existing health complexities at the point of care. However, these forms have faced significant implementation challenges that lead to limited stakeholder buy-in and lack of incorporation into current emergency care workflows. We present HCD as a strategy to aid in the creation and optimization of an emergency care action plan (ECAP) for CMC. The objectives of this communication are, therefore, as follows: (1) to demonstrate HCD as an accessible approach to delineate and address pediatric care challenges within a complex health care system and (2) to illustrate a commonly used HCD methodological approach to address implementation challenges of an emergency care planning tool through the creation of an ECAP for CMC.

Comparing Leadership Skills of Senior Emergency Medicine Residents in 3-Year Versus 4-Year Programs During Simulated Pediatric Resuscitation: A Pilot Study

OBJECTIVES

The majority of pediatric patients in the United States (US) are evaluated and treated at general emergency departments. It is possible that discrepancies in length of emergency medicine (EM) residency training may allow for variable exposure to pediatric patients, critical resuscitations, and didactic events. The goal of this pilot study was to compare leadership skills of graduating EM residents from 3- to 4-year programs during simulated pediatric resuscitations using a previously validated leadership assessment tool, the Concise Assessment of Leader Management (CALM).

METHODS

This was a prospective, multicenter, simulation-based cohort pilot study that included graduating 3 rd - and 4 th -year EM resident physicians from 6 EM residency programs. We measured leadership performance across 3 simulated pediatric resuscitations (sepsis, seizure, cardiac arrest) using the CALM tool and compared leadership scores between the 3 rd - and 4 th -year resident cohorts. We also correlated leadership to self-efficacy scores.

RESULTS

Data was analyzed for 47 participating residents (24 3 rd -year residents and 23 4 th -year residents). Out of a total possible CALM score of 66, residents from 3-year programs scored 45.2 [SD ± 5.2], 46.8 [SD ± 5.0], and 46.6 [SD ± 4.7], whereas residents from 4-year programs scored 45.5 [SD ± 5.2], 46.4 [SD ± 5.0], and 48.2 [SD ± 4.3] during the sepsis, seizure, and cardiac arrest cases, respectively. The mean leadership score across all 3 cases for the 3-year cohort was 46.2 [SD ± 4.8] versus 46.7 [SD ± 4.5] ( P = 0.715) for the 4-year cohort.

CONCLUSIONS

These data show feasibility for a larger cohort project and, while not statistically significant, suggest no difference in leadership skills between 3 rd - and 4 th -year EM residents in our study cohort. This pilot study provides the basis of future work that will assess a larger multicenter cohort with the hope to obtain a more generalizable dataset.

Reported costs of children with medical complexity-A systematic review

Examining reported costs for Children with Medical Complexity (CMCs) is essential because costing and resource utilization studies influence policy and operational decisions. Our objectives were to (1) examine how authors identified CMCs in administrative databases, (2) compare reported costs for the CMC population in different study settings, and (3) analyze author recommendations related to reported costs. We undertook a systematic search of the following databases: Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library with a focus on CMCs as a heterogeneous group. The most common method used n = 11 (41%) to identify the CMC population in administrative data was the Complex Chronic Conditions methodology. The majority of included studies reported on health care service costs n = 24 (89%). Only n = 3 (11%) of the studies included costs from the family perspective. Author recommendations included standardizing how costs are reported and including the family perspective when making care delivery or policy decisions. Health system administrators and policymakers must consider the limitations of reported costs when assessing local costing studies or comparing costs across jurisdictions.

Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates

Background

More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency.

Methods

This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email.

Results

A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001).

Conclusions/discussion

This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.

Emergency Department Use by Young Adults With Chronic Illness Before and During the COVID-19 Pandemic

INTRODUCTION

There was a significant decrease in emergency department encounters during the COVID-19 pandemic. Our large urban emergency department observed decreased encounters and admissions by youths with chronic health conditions. This study aimed to compare the frequency of emergency department encounters for certain young adults before the pandemic and during the COVID-19 pandemic.

METHODS

A retrospective cohort study using medical records of patients ages 20 to 26 years from October 2018 to September 2019 and February 2020 to February 2021. Files set for inclusion were those with a primary diagnosis of human immunodeficiency virus, diabetes mellitus, epilepsy, cerebral palsy, sickle cell disease, asthma, and certain psychiatric disorders for potentially preventable health events.

RESULTS

We included 1203 total encounters (853 before the pandemic and 350 during the pandemic), with the total number of subjects included in the study 568 (293 before the pandemic to 239 during the pandemic). During the pandemic, young adults with mental health conditions (53.1%) accounted for most encounters. Encounters requiring hospital admissions increased from 27.4% to 52.5% during the pandemic, primarily among patients with diabetes (41.8% vs 61.1%) and mental health conditions (50% vs 73.3%).

DISCUSSION

The number of young adults with certain chronic health conditions decreased during COVID-19, with encounters for subjects with mental health conditions increasing significantly. The proportion of admissions increased during the pandemic with increases for subjects with mental health disorders and diabetes. The number of frequent users decreased during COVID-19. Future research is needed to understand better the causes for these disparities in young adults with chronic conditions who use the emergency department as a source of care.

An assessment of information needs and workflows for emergency service providers and caregivers of children with medical complexity

BACKGROUND

The goal of Project Austin, an initiative to improve emergency care for rural children who are medically complex (CMC), is to provide an Emergency Information Form (EIF) to their parents/caregivers, to local Emergency Medical Services, and Emergency Departments. EIFs are standard forms recommended by the American Academy of Pediatrics that provide pre-planned rapid response instructions, including medical conditions, medications, and care recommendations, for emergency providers. Our objective is to describe the workflows and perceived utility of the provided emergency information forms (EIFs) in the acute medical management of CMC.

METHODS

We sampled from two key stakeholder groups in the acute management of CMC: four focus groups with emergency medical providers from rural and urban settings and eight key informant interviews with parents/caregivers enrolled in an emergency medical management program for CMC. Transcripts were thematically analyzed in NVivo© by two coders using a content analysis approach. The thematic codes were combined into a codebook and revised the themes present through combining relevant themes and developing of sub-themes until they reached consensus.

RESULTS

All parents/caregivers interviewed were enrolled in Project Austin and had an EIF. Emergency medical providers and parents/caregivers supported the usage of EIFs for CMC. Parents/caregivers also felt EIFs made emergency medical providers more prepared for their child. Providers identified that EIFs helped provide individualized care, however they were not confident the data was current and so felt unsure they could rely on the recommendations on the EIF.

CONCLUSION

EIFs are an easy way to engage parents, caregivers, and emergency medical providers about the specifics of a care for CMC during an emergency. Timely updates and electronic access to EIFs could improve their value for medical providers.

The Current State of Pediatric Emergency Medicine Training in Emergency Medicine Residencies

BACKGROUND

Several studies show that emergency medicine (EM) physicians are less comfortable caring for pediatric patients than adults. The state of pediatric training has not been comprehensively evaluated since 2000.

OBJECTIVES

We sought to describe current pediatric education in EM residencies and to evaluate EM Program Director (PD) confidence in graduating trainees' abilities to care for pediatric patients.

METHODS

We conducted an anonymous, cross-sectional survey study of EM PDs in August 2020. We collected program demographics, clinical rotations, and didactic methods. We used Likert scales to measure PD confidence in graduating residents' competence to care for pediatric and adult patients.

RESULTS

We found e-mail addresses for 249 (93%) of 268 EM programs. One hundred nineteen (48%) PDs completed the survey. We include denominators to account for unanswered questions. Sixty-eight (59%) of 116 programs spend 10% to 20% of clinical time seeing pediatric patients. One hundred ten (91%) of 119 require a pediatric emergency medicine (PEM) rotation, 88/119 (83%) require pediatric intensive care, and 34/119 (29%) require neonatal intensive care. Seventy (62%) of 113 have curricula designed by PEM-trained faculty, 96/113 (85%) have PEM attendings teach lectures, and 77/113 (68%) spend 10% to 20% of didactic time on pediatric topics. Twenty-three (23%) of 106 PDs stated not all residents graduate with competence in pediatric resuscitation compared with 2/106 (2%) for adult resuscitation ( P < 0.05).

CONCLUSIONS

Program directors report less confidence in graduating residents' competence in caring for pediatric patients compared with adult patients. We propose ideas to strengthen the quality of pediatric education in EM residencies.

Organisational models at the emergency department to reduce hospital admissions among paediatric patients: a systematic literature review

Paediatric attendances at the emergency department (ED) are often admitted to the hospital less than 24 h to allow time for more extended evaluation. Innovative organisational models could prevent these hospital admissions without compromising safety or quality of delivered care. Therefore, this systematic review identifies evidence on organisational models at the ED with the primary aim to reduce hospital admissions among paediatric patients. Following the PRISMA guidelines, three bibliographic databases (Ovid Medline, Embase, and Cochrane Library) were searched. Studies on organisational models in Western countries, published between January 2009 and January 2021, which applied a comparative design or review and studied at least hospital admission rates, were included. Analyses were mainly descriptive because of the high heterogeneity among included publications. The primary outcome is hospital admission rates. Secondary outcomes are ED length of stay (LOS), waiting time, and patient satisfaction. Sixteen publications described several innovative organisational models ranging from the creation of dedicated units for paediatric patients, innovative staffing models to bringing paediatric critical care physicians to patients at rural EDs. However, the effect on hospital admission rates and other outcomes are inconclusive, and some organisational models may improve certain outcomes in certain settings or vice versa. It appears that a paediatric consultation liaison team has the most consistent effect on hospital admission rates and LOS of paediatric patients presenting with mental problems at the ED. Implementing new innovative organisational models at the ED for paediatric patients could be worthwhile to decrease hospital admissions. However, the existing evidence is of rather weak quality. Future service developments should, therefore, be conducted in a way that allows objective evaluation.

Pediatric Emergency Medicine Physicians' Perspectives on Emergency Care of Children With Medical Complexity: A Multi-institution Mixed-Methods Assessment

OBJECTIVE

Children with medical complexity (CMC) compose 1% of the pediatric population but account for 20% of pediatric emergency department (ED) visits. Previous descriptions of challenges and interventions to ensure quality of care are limited. Our objective was to elicit pediatric emergency medicine (PEM) physicians' perspectives on challenges and opportunities for improvement of emergency care of CMC, with a focus on emergency information forms (EIFs).

METHODS

We conducted a web-based survey of PEM physicians participating the American Academy of Pediatrics Section on Emergency Medicine Survey listserv. The survey was designed using an expert panel, and subsequently piloted and revised to an 18-item survey. Data were analyzed with descriptive statistics.

RESULTS

One hundred fifty-one of 495 respondents (30%) completed the survey. Most respondents (62.9%) reported caring for >10 CMC per month. Whereas overall medical fragility and time constraints were major contributors to the challenges of caring for CMC in the ED, communication with known providers and shared care plans were identified as particularly helpful. Most respondents did not report routine use of EIFs. Anticipated emergencies/action plan was deemed the most important component of EIFs.

CONCLUSIONS

Most PEM physicians view the care for CMC in the ED as challenging despite practicing in high-resource environments. Further research is needed to develop and implement strategies to improve care of CMC in the ED. Understanding experiences of providers in general ED settings is also an important next step given that 80% of CMC present for emergency care outside of major children's hospitals.

Impact of the COVID-19 Pandemic on the Pediatric Hospital Visits: Evidence from the State of Florida

Although early evidence reported a substantial decline in pediatric hospital visits during COVID-19, it is unclear whether the decline varied across different counties, particularly in designated Medically Underserved Areas (MUA). The objective of this study is to explore the state-wide impact of COVID-19 on pediatric hospital visit patterns, including the economic burden and MUA communities. We conducted a retrospective observational study of pediatric hospital visits using the Florida State all-payer Emergency Department (ED) and Inpatient dataset during the pandemic (April-September 2020) and the same period in 2019. Pediatric Treat-and-Release ED and inpatient visit rates were compared by patient demographics, socioeconomic, diagnosis, MUA status, and hospital characteristics. Pediatric hospital visits in Florida decreased by 53.7% (62.3% in April-June, 44.2% in July-September) during the pandemic. The Treat-and-Release ED and inpatient visits varied up to 5- and 3-fold, respectively, across counties. However, changes in hospital visits across MUA counties were similar compared with non-MUA counties except for lower Treat-and-Release ED volume in April-May. The disproportional decrease in visits was notable for the underserved population, including Hispanic and African American children; Medicaid coverages; non-children's hospitals; and diagnosed with respiratory diseases, appendicitis, and sickle-cell. Florida Hospitals experienced a USD 1.37 billion (average USD 8.3 million) decline in charges across the study period in 2020. Disproportionate decrease in hospital visits, particularly in the underserved population, suggest a combined effect of the persistent challenge of care access and changes in healthcare-seeking behavior during the pandemic. These findings suggest that providers and policymakers should emphasize alternative interventions/programs ensuring adequate care during the pandemic, particularly for high-risk children.

Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions

OBJECTIVE

Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC.

METHODS

A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit.

RESULTS

Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5]).

CONCLUSIONS

Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings.

2017 AAAEM Benchmarking Survey: Comparing Pediatric and Adult Academic Emergency Departments

OBJECTIVES

The Academy of Administrators in Academic Emergency Medicine Benchmark Survey of academic emergency departments (EDs) was conducted in 2017. We compared operational measures between pediatric and adult (defined as fewer than 5% pediatric visits) EDs based on survey data. Emergency departments in dedicated pediatric hospitals were not represented.

METHODS

Measures included: (1) patient volumes, length of stay, and acuity; and 2) faculty staffing, productivity, and percent effort in academics. t Tests were used to compare continuous measures and inferences for categorical variables were made using Pearson χ2 test.

RESULTS

The analysis included 17 pediatric and 52 adult EDs. We found a difference in the number of annual visits between adult (median, 66,275; interquartile range [IQR], 56,184-77,702) and pediatric EDs (median, 25,416; IQR, 19,840-29,349) (P < 0.0001). Mean "arrivals per faculty clinical hour" and "total arrivals per treatment space" showed no differences. The proportion of visits (1) arriving by emergency medical services and (2) for behavioral health were significantly higher in adult EDs (both P < 0.0001). The mean length of stay in hours for "all" patients was significantly longer in adult (5.4; IQR, 5.0-6.6) than in pediatric EDs (3.5; IQR, 2.9-4.3; P = 0.017). A similar difference was found for "discharged" patients (P = 0.004). Emergency severity indices, professional evaluation and management codes, and hospitalization rates all suggest higher acuity in adult EDs (all P < 0.0001). There were no differences in mean work relative value units per patient or in the distribution of full time equivalent effort dedicated to academics.

CONCLUSIONS

In this cohort, significant differences in operational measures exist between academic adult and pediatric EDs. No differences were found when considering per unit measures, such as arrivals per faculty clinical hour or per treatment space.

Evaluation of the 2020 Pediatric Emergency Physician Workforce in the US

IMPORTANCE

Given the mortality disparities among children and adolescents in rural vs urban areas, the unique health care needs of pediatric patients, and the annual emergency department volume for this patient population, understanding the availability of pediatric emergency physicians (EPs) is important. Information regarding the available pediatric EP workforce is limited, however.

OBJECTIVE

To describe the demographic characteristics, training, board certification, and geographic distribution of the 2020 clinically active pediatric EP workforce in the US.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional study of the 2020 pediatric EP workforce used the American Medical Association Physician Masterfile database, which was linked to American Board of Medical Specialties board certification information. Self-reported training data in the database were analyzed to identify clinically active physicians who self-reported pediatric emergency medicine (EM) as their primary or secondary specialty. The Physician Masterfile data were obtained on March 11, 2020.

MAIN OUTCOMES AND MEASURES

The Physician Masterfile was used to identify all clinically active pediatric EPs in the US. The definition of EM training was completion of an EM program (inclusive of both an EM residency and/or a pediatric EM fellowship) or a combined EM program (internal medicine and EM, family medicine and EM, or pediatrics and EM). Physician location was linked and classified by county-level Urban Influence Codes. Pediatric EP density was calculated and mapped using US Census Bureau population estimates.

RESULTS

A total of 2403 clinically active pediatric EPs were working in 2020 (5% of all clinically active emergency physicians), of whom 1357 were women (56%) and the median (interquartile range) age was 46 (40-55) years. The overall pediatric EP population included 1718 physicians (71%) with EM training and 641 (27%) with pediatric training. Overall, 1639 (68%) were board certified in pediatric EM, of whom 1219 (74%) reported EM training and 400 (24%) reported pediatrics training. Nearly all pediatric EPs worked in urban areas (2369 of 2402 [99%]), and pediatric EPs in urban compared with rural areas were younger (median [interquartile range] age, 46 [40-55] years vs 59 [48-65] years). Pediatric EPs who completed their training 20 years ago or more compared with those who completed training more recently were less likely to work in urban settings (633 [97%] vs 0-4 years: 440 [99%], 5-9 years: 547 [99%], or 10-19 years: 723 [99%]; P = .006). Three states had 0 pediatric EPs (Montana, South Dakota, and Wyoming), and 3 states had pediatric EPs in only 1 county (Alaska, New Mexico, and North Dakota). Less than 1% of counties had 4 or more pediatric EPs per 100 000 population.

CONCLUSIONS AND RELEVANCE

This study found that almost all pediatric EPs worked in urban areas, leaving rural areas of the US with limited availability of pediatric emergency care. This finding may have profound implications for children and adolescents needing emergency care.

Preventing Emergency Department Visits for Children With Medical Complexity Through Ambulatory Care: A Systematic Review

BACKGROUND

Children with medical complexity (CMC) represent a growing population with high emergency department (ED) utilization. How to reduce preventable ED visits is poorly understood.

OBJECTIVE

We sought to determine what components of ambulatory care programs focused on CMC were most effective in preventing ED visits.

DATA SOURCES

PubMed Plus, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases through October 2019, and hand search of bibliographies.

STUDY ELIGIBILITY CRITERIA

Two independent reviewers used a structured screening protocol to include English language articles summarizing studies that included CMC, emergency care, or ED utilization. Data on ED utilization were extracted.

RESULTS

Sixteen included studies described outpatient interventions to prevent ED utilization. Of these, studies that included 24/7 access to knowledgeable providers for acute care needs by phone (telehealth) or expedited or next-day appointments were the most consistently successful in reducing ED visits.

LIMITATIONS

Risk of bias was mixed across studies. The evidence base is currently small and observational nature of interventions and their evaluations limit definitive, generalizable recommendations.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Current research suggests that real-time access to knowledgeable providers and expedited appointments can prevent ED visits. Further study is needed to generalize these findings as well as investigate novel strategies such as telehealth to improve quality of care, decrease utilization, and provide cost-effective care for this vulnerable population.

Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees?

BACKGROUND

The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training.

METHODS

This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument.

RESULTS

A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%).

CONCLUSIONS

This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.

A Descriptive Analysis of the Cumulative Experiences of Emergency Medicine Residents in the Pediatric Emergency Department

OBJECTIVES

Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine.

METHODS

Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition.

RESULTS

Twenty-five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses.

CONCLUSIONS

Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

Improving Emergency Care for Children With Medical Complexity: Parent and Physicians' Perspectives

OBJECTIVE

Children with medical complexity (CMC) have high rates of emergency department (ED) utilization, but little evidence exists on the perceptions of parents and pediatric emergency medicine (PEM) physicians about emergency care. We sought to explore parent and PEM physicians' perspectives about 1) ED care for CMC, and 2) how emergency care can be improved.

METHODS

We performed semistructured interviews with parents and PEM physicians at a single academic, children's hospital. English-speaking parents were selected utilizing a standard definition of CMC during an ED visit in which their child was admitted to the hospital. All PEM physicians were eligible. We developed separate interview guides utilizing open-ended questions. The trained study team developed and modified a coding tree through an iterative process, double-coded transcripts, monitored inter-rater reliability to ensure adherence, and performed thematic analysis.

RESULTS

Twenty interviews of parents of CMC and 16 of PEM physicians were necessary for saturation. Parents identified specific challenges related to ED care of their children involving time, information gathering, logistics/convenience, and multifaceted communication between health teams and parents. PEM physicians identified time, data accessibility and availability, and communication as inter-related challenges in caring for CMC in the ED. Suggestions reflected potential solutions to the challenges identified.

CONCLUSIONS

Time, data, and communication challenges were the main focus for both parents and PEM physicians, and suggestions mirrored these challenges. Further research and quality improvement efforts to better characterize and mitigate the identified challenges could be of value for this vulnerable population.

Pediatric emergency department utilization during the COVID-19 pandemic in New York City

Objectives

This study describes the utilization of a pediatric emergency department (ED) during the early months of the COVID-19 pandemic in the initial U.S. epicenter, including the impact on visit acuity and incidences of common diagnoses.

Study Design

We performed an observational retrospective review of patients younger than 18 years old seen in a New York City pediatric ED from March 7th to May 6th 2020, and during the same time period in 2018 and 2019. Demographics, visit details, diagnoses, and dispositions were compared. Validated algorithms were utilized to create practical diagnosis groupings and to determine the probability of a visit requiring emergent evaluation.

Results

ED visits during the pandemic decreased by 56% to an average daily census of 67 patients, from an anticipated 152. Admission rates rose from 13.3% to 17.4% (p<0.001), and the proportion of triage Emergency Severity Index level 1 and 2 patients increased by 23.7% (p<0.001). Non-emergent visits dropped from 32.3% to 27.5% (p<0.001). Several common, often low-acuity diagnoses saw disproportionate reductions in visits including headache, chest pain, and minor injuries. Concerningly, visits for suicidal ideation, suicide attempt, or self-harm increased by 100% (p<0.001) and visits for evaluating abuse or neglect decreased by 89% (p=0.01).

Conclusions

Pediatric ED utilization substantially deceased during the early months of the COVID-19 pandemic in New York City, but left relatively higher patient acuity. Healthcare systems in early epicenters must also prepare for the disproportionate impact a pandemic has on the most vulnerable pediatric patients, particularly those at risk for self-harm or abuse.

Pediatric Preparedness of the Emergency Departments

OBJECTIVES

Emergency departments (EDs) varied in their preparedness to provide pediatric emergency care, with mortality rates being higher when EDs were unprepared. Guidelines are available to aid EDs in their preparedness. We aimed to determine the preparedness of EDs in our healthcare cluster using the guidelines from the Royal College of Pediatrics and Child Health (RCPCH) and International Federation for Emergency Medicine (IFEM) as references for audit.

METHODS

This was a cross-sectional study involving a pediatric ED and 3 general EDs within a healthcare cluster. A survey was completed by a pediatric representative at each ED who assessed his/her own ED's effort against each recommended standard with reference to calendar year of 2018. The availability of pediatric equipment, supplies, and medications was checked against the items recommended list by the IFEM.

RESULTS

The response rate was 100%. The proportion of agreement with reference standards was lower for general EDs (RCPCH: 11.4%-70.0% and IFEM: 39.6%-84.0%) than pediatric ED (RCPCH: 85.7% and IFEM: 91.7%). Unmet standards were predominantly in the categories of management of pediatric patients with complex medical needs, management of pediatric death, adolescents, mental health and substance misuse, protection and safeguarding of pediatric patients, as well as advanced training and research. The proportion of available equipment, supplies, and medications was also lower for general EDs (77.2%-82.0%) than pediatric ED (89.4%).

CONCLUSIONS

The standards of pediatric emergency care were met to different extents in the healthcare cluster. Using available references, EDs should identify lapses unique to their own settings to improve the delivery of pediatric emergency care.

Children with special health care needs attending emergency department in Italy: analysis of 3479 cases

BACKGROUND

Although children with special health care needs (CSHCN) represent a minority of the population, they go through more hospitalizations, more admissions to the Emergency Department (ED), and receive a major number of medical prescriptions, in comparison to general pediatric population. Objectives of the study were to determine the reasons for admission to the ED in Italian CSHCN, and to describe the association between patient's demographic data, clinical history, and health services requirements.

METHODS

Ad hoc web site was created to collect retrospective data of 3479 visits of CSHCN to the ED in 58 Italian Hospitals.

RESULTS

Seventy-two percent of patients admitted to ED were affected by a previously defined medical condition. Most of the ED admissions were children with syndromic conditions (54%). 44.2% of the ED admissions were registered during the night-time and/or at the weekends. The hospitalization rate was of 45.6% among patients admitted to the ED. The most common reason for admission to the ED was the presence of respiratory symptoms (26.6%), followed by gastrointestinal problems (21.3%) and neurological disorders (18.2%). 51.4% of the access were classified as 'urgent', with a red/yellow triage code. Considering the type of ED, 61.9% of the visits were conducted at the Pediatric EDs (PedEDs), 33.5% at the Functional EDs (FunEDs) and 4.6% at the Dedicated EDs (DedEDs). Patients with more complex clinical presentation were more likely to be evaluated at the PedEDs. CSHCN underwent to a higher number of medical procedures at the PedEDs, more in comparison to other EDs. Children with medical devices were directed to a PedED quite exclusively when in need for medical attention. Subjects under multiple anti-epileptic drug therapy attended to PedEDs or FunEDs generally. Patients affected by metabolic diseases were more likely to look for medical attention at FunEDs. Syndromic patients mostly required medical attention at the DedEDs.

CONCLUSIONS

Access of CSHCN to an ED is not infrequent. For this reason, it is fundamental for pediatricians working in any kind of ED to increase their general knowledge about CHSCN and to gain expertise in the management of such patients and their related medical complexity.

Assessing the effectiveness of pediatric emergency medicine education in emergency medicine residency training: A national survey

Background:

Evaluating the effectiveness of pediatric emergency medicine training is essential to ensure that emergency physicians and emergency medicine residents have sufficient knowledge, skill, and confidence in optimizing care for acute pediatric visits. Although the field of pediatric emergency medicine has experienced phenomenal growth in past decades, it still faces challenges in how to best implement the curriculums in emergency medicine residency training programs.

Objectives:

Exploring emergency physicians’ and emergency residents’ perspectives on pediatric emergency medicine training in emergency residency training programs in Taiwan through a nationwide survey.

Methods:

The survey was distributed to 1281 emergency physicians and emergency medicine residents in 43 teaching hospitals. The survey inquired about demographic data, hospital type, rank of proctored trainers and assessors, and the setting of pediatric emergency medicine training. Participants’ confidence in managing acute pediatric visits and their satisfaction and reflections of their pediatric emergency medicine training were explored.

Results:

In all, 258 responses were received from 117 residents and 141 emergency physicians. Seventy-seven percent reported working in medical centers. Clinical supervision was primarily performed by pediatric attending physicians and emergency physicians. Fifty-eight percent of participants felt satisfied with their pediatric emergency medicine training. However, only 52.3% felt confident managing acute pediatric visits, which was attributed to inadequate exposure to pediatric patients. Residents noted lack of confidence in managing newborns, infants, and clinical procedures. Therefore, simulation training and point-of-care ultrasound learning were considered advantageous.

Conclusion:

The pediatric emergency medicine training in emergency medicine residency programs is diverse in intensive care training, supervisors, and assessors. Surveys demonstrate that learning experience in pediatric wards and emergency department rotations is associated with overall satisfaction with pediatric emergency medicine training; inadequate exposure to pediatric patients contributed to learners having less confidence. Emergency medicine residency program reform might focus on adequate hands-on pediatric patient care.

Caring for Children With Medical Complexity With the Emergency Information Form

BACKGROUND AND OBJECTIVE

The American Academy of Pediatrics recommends an emergency information form (EIF) for children with medical complexity (CMC) to facilitate emergency care. We sought to increase the EIF completion rate at our children's hospital's CMC clinic and to evaluate the effect on caregiver and emergency department (ED) provider opinion of preparation, comfort, and communication.

METHODS

We used a pre/post-quality improvement design. The main outcomes were (1) the proportion of completed EIFs and (2) caregiver and ED provider opinion of preparation, comfort, and communication, using a Likert scale survey (1, low; 5, high).

RESULTS

Emergency information form completion increased from 3.1% (4/133) before the intervention to 47.0% (78/166) after (P < 0.001). Twenty-three providers completed presurveys, and 8 completed postsurveys. Seventy-two caregivers completed presurveys, and 38 completed postsurveys (25 with ED visit and 13 without). There were no changes in preparation, comfort, or communication for caregivers who had an ED visit after the intervention. For those without a postintervention ED visit, caregiver median scores rose for preparation (4 [interquartile range {IQR}, 3-5] vs 5 [IQR, 4-5], P = 0.02) and comfort (4 [IQR, 2.25-5] vs 5 [IQR, 4-5], P = 0.05). After the intervention, ED providers had increased median communication scores (3 [IQR, 2.75-4.25] vs 5 [IQR, 4-5], P = 0.02), whereas scores of preparation and comfort were unchanged.

CONCLUSION

A quality improvement project at a CMC clinic increased EIF completion, caregiver preparation and comfort, and ED provider communication in emergencies.

Variation in Hospitalization Rates Following Emergency Department Visits in Children with Medical Complexity

OBJECTIVES

To evaluate factors associated with admission from emergency department (ED) encounters for children with medical complexity (CMC) and to quantify the hospital admission rate as well as variation in adjusted hospital admission rates across EDs.

STUDY DESIGN

Retrospective study of 271 806 visits to 37 EDs in freestanding children's hospitals from January 1, 2014, to June 30, 2017, for patients of all ages with a complex chronic condition. Associations between patient demographic, clinical, and health services characteristics and the likelihood of hospital admission were identified using generalized linear models, which were then used to calculate adjusted hospital admission rates.

RESULTS

Hospital admission occurred with 25.7% of ED visits. Characteristics with the greatest aOR of hospitalization were ≥3 compared with 0 prior hospitalizations in 365 days (4.7; 95% CI, 4.5-4.9), ED arrival overnight compared with during workday 3.2 (95% CI, 3.1-3.3)], and ≥6 vs 0-1 chronic conditions (1.6; 95% CI, 1.5-1.6). Adjusted hospital admission rates varied significantly (P < .001) across EDs (21.1% [10th percentile]) and 30.0% [90th percentile]). Significant variation remained when excluding low-intensity ED visits, excluding hospitalizations requiring surgery and/or intensive care, or restricting the cohort to overnight ED arrival and to children with ≥3 prior hospitalizations.

CONCLUSIONS

CMC are frequently admitted from the ED. Substantial variation in CMC hospital admission rates across EDs exists after case-mix adjustment.

Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community

OBJECTIVES

Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited.

METHODS

In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population.

RESULTS

Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background.

CONCLUSIONS

Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.

The Care of Adult Patients in Pediatric Emergency Departments

OBJECTIVE

Adult patients are increasingly receiving care in pediatric emergency departments (PEDs), but little is known about the epidemiology of these visits. The goals of this study were to examine the characteristics of adult patients (≥21 years) treated in PEDs and to describe the variation in resource utilization across centers.

METHODS

We conducted a cross-sectional study examining visits to 30 PEDs (2012-2016) using the Pediatric Health Information System. Visits were categorized using All Patient Refined Diagnosis Related Groups and compared between age cohorts. We used multivariable logistic models to examine variation in demographics, utilization, testing, treatment, and disposition.

RESULTS

There were 12,958,626 visits to the 30 PEDs over 5 years; 70,636 (0.6%) were by adults. Compared with children, adult patients had more laboratory testing (49% vs 34%), diagnostic imaging (32% vs 29%), and procedures (48% vs 31%), and they were more often admitted (17% vs 11%) or transferred (21% vs 0.7%) (P < .001 for all). In multivariable analysis, older age, black race, Hispanic ethnicity, and private insurance were associated with decreased odds of admission in adults seen in PEDs. Across PEDs, the admission rates (7%-25%) and transfer rates (6%-46%) for adults varied.

CONCLUSIONS

Adult patients cared for at PEDs have higher rates of testing, diagnostic imaging, procedures, and admission or transfer. There is wide variation in the care of adults in PEDs, highlighting the importance of further work to identify the optimal approach to adults who present for care in pediatric centers.

Use of a National Database to Assess Pediatric Emergency Care Across United States Emergency Departments

OBJECTIVES

Differences in emergency care for children exist between general and pediatric emergency departments (EDs). Some pediatric quality measures are available but are not routinely employed nationwide. We sought to create a short list of applied measures that would provide a starting point for EDs to measure pediatric emergency care quality and to compare care between general and pediatric EDs for these measures.

METHODS

Previously reported lists comprising 465 pediatric emergency care quality measures were reconciled. Preset criteria were used to create a diverse list of quality measures measurable using a national database. We used the National Hospital Ambulatory Medical Care Survey from 2010 to 2015 to measure performance. Measures were excluded for total observation counts under a prespecified power threshold, being unmeasurable in the data set, or for missing clear definitions. Using survey-weighted statistics, we reported summary performance (mean, proportion, or count) with 95% confidence intervals for each analyzed quality measure and compared general and pediatric ED performance.

RESULTS

Among 465 quality measures, 28 (6%) were included in the analysis, including seven condition-specific measures and 21 general measures. We analyzed a sample of 36,430 visits corresponding to 179.0 million survey-weighted ED visits, of which 150.8 million (84.3%) were in general EDs. Performance was better in pediatric EDs for three of seven condition-specific measures, including antibiotics for viral infections (-6.2%), chest X-rays for asthma (-18.7%), and topical anesthesia for wound closures (+25.7%). Performance was similar for four of seven condition-specific measures: computed tomography for head trauma, steroids for asthma, steroids for croup, and oral rehydration for dehydration. Compared with pediatric EDs, general EDs discharged and transferred higher proportions of children, had shorter lengths of stay, and sent patients home with fewer prescriptions. General EDs obtained fewer pain scores for injured children. Pediatric EDs had a lower proportion of pediatric visits in which patients left against medical advice. General and pediatric EDs had similar rates of mortality, left without being seen, incomplete vital signs, labs in nonacute patients, and similar numbers of medications given per patient.

CONCLUSIONS

Using a national sample of ED visits, we demonstrated the feasibility of using nationally representative data to assess quality measures for children cared for in the ED. Differences between pediatric and general ED care identify targets for quality improvement.

External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma

BACKGROUND

Computed tomography (CT) is frequently used to identify intra-abdominal injuries in children with blunt abdominal trauma (BAT). The Pediatric Emergency Care Applied Research Network (PECARN) proposed a prediction rule to identify children with BAT who are at very low risk for clinically-important intra-abdominal injuries (CIIAI) in whom CT can be avoided.

OBJECTIVE

To determine the sensitivity of this prediction rule in identifying patients at very low risk for CIIAI in our pediatric trauma registry.

METHODS

Retrospective review of our institutional trauma registry to identify patients with CIIAI. CIIAI included cases resulting in death, therapeutic intervention at laparotomy, angiographic embolization of intra-abdominal arterial bleeding, blood transfusion for intra-abdominal hemorrhage, and administration of intravenous fluids for two or more nights for pancreatic or gastrointestinal injuries. Patients were identified using ICD diagnosis and procedure codes. Kappa was calculated to evaluate inter-reviewer agreement.

RESULTS

Of 5743 patients, 133 (2.3%) had CIIAI. 60% were male and the mean age was 8 (SD 4.4) years. One patient with CIIAI met the proposed very low risk criteria, resulting in a prediction rule sensitivity of 99%, 95% CI [96-100%]. This patient also had extra-abdominal arterial bleeding requiring revascularization, offering an alternative reason for transfusion. Kappa was 0.85, 95% CI [0.82, 0.89], indicating strong inter-rater agreement.

CONCLUSIONS

One out of 133 patients with CIIAI met very low risk criteria based on the PECARN prediction rule. This study supports the PECARN clinical prediction rule in decreasing CT use in pediatric patients at very low risk for CIIAI.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time

BACKGROUND

The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children.

OBJECTIVES

To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes.

METHODS

We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics.

RESULTS

From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%).

CONCLUSIONS

Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

Emergency Information Forms for Children With Medical Complexity: A Simulation Study

BACKGROUND

Emergency information forms (EIFs) have been proposed to provide critical information for optimal care of children with medical complexity (CMC) during emergencies; however, their impact has not been studied. The objective of this study was to measure the impact and utility of EIFs in simulated scenarios of CMC during medical emergencies.

METHODS

Twenty-four providers (12 junior, 12 experienced) performed 4 simulations of CMC, where access to an EIF was block randomized by group. Scenario-specific critical action checklists and consequential pathways were developed by content experts in simulation and pediatric subspecialists. Scenarios ended when all critical actions were completed or after 10 minutes, whichever came first. Two reviewers independently evaluated the video-recorded performances and calculated scenario-specific critical action scores. Performance in scenarios with and without an EIF was compared with Pearson's χ(2) and Mann-Whitney U tests. Interrater reliability was assessed with intraclass correlation. Each provider rated the utility of EIFs via exit questionnaires.

RESULTS

The median critical action score in scenarios with EIFs was 84.2% (95% confidence interval [CI], 71.7%-94.1%) versus 12.5% (95% CI, 10.5%-35.3%) in scenarios without an EIF (P < .001); time to completion of scenarios was shorter (6.9 minutes [interquartile range 5.8-10 minutes] vs 10 minutes), and complication rates were lower (30% [95% CI, 17.4%-46.3%] vs 100% [95% CI, 92.2%-100%]) with EIFs, independent of provider experience. Interrater reliability was excellent (intraclass correlation = 0.979). All providers strongly agreed that EIFs can improve clinical outcomes for CMC.

CONCLUSIONS

Using simulated scenarios of CMC, providers' performance was superior with an EIF. Clinicians evaluated the utility of EIFs very highly.

Clusters of Multiple Complex Chronic Conditions: A Latent Class Analysis of Children at End of Life

CONTEXT

Children at end of life often experience multiple complex chronic conditions with more than 50% of children reportedly having two or more conditions. These complex chronic conditions are unlikely to occur in an entirely uniform manner in children at end of life. Previous work has not fully accounted for patterns of multiple conditions when evaluating care among these children.

OBJECTIVES

The objective of the study was to understand the clusters of complex chronic conditions present among children in the last year of life.

METHODS

Participants were 1423 pediatric decedents from the 2007 to 2008 California Medicaid data. A latent class analysis was used to identify clusters of children with multiple complex chronic conditions (neurological, cardiovascular, respiratory, renal, gastrointestinal, hematologic, metabolic, congenital, cancer). Multinomial logistic regression analysis was used to examine the relationship between demographic characteristics and class membership.

RESULTS

Four latent classes were yielded: medically fragile (31%); neurological (32%); cancer (25%); and cardiovascular (12%). Three classes were characterized by a 100% likelihood of having a complex chronic condition coupled with a low or moderate likelihood of having the other eight conditions. The four classes exhibited unique demographic profiles.

CONCLUSION

This analysis presented a novel way of understanding patterns of multiple complex chronic conditions among children that may inform tailored and targeted end-of-life care for different clusters.

Asthma outcomes in children and adolescents with multiple morbidities: Findings from the National Health Interview Survey

BACKGROUND

More Americans are managing multiple chronic conditions (MCCs), and trends are particularly alarming in youth.

OBJECTIVE

The purpose of this study was to examine the prevalence and distribution of 9 chronic conditions in children and adolescents with and without asthma, and adverse asthma outcomes associated with having MCCs.

METHODS

Cross-sectional interview data from the National Health Interview Survey were analyzed (N = 66,790) between 2007 and 2012 in youth 0 to 17 years of age. Bivariate analysis methods and multivariate generalized linear regression were used to examine associations.

RESULTS

Five percent of children with asthma had 1 or more coexisting health conditions. The prevalence of 1 or more comorbidities was greater among those with asthma than those without (5.07% [95% CI: 4.5-5.6] vs. 2.73% [95% CI: 2.6-2.9]). Those with asthma were twice as likely to have co-occurring hypertension (prevalence ratio [PR] = 2.2 [95% CI: 1.5-3.2]) and arthritis (PR = 2.7 [95% CI: 1.8-4.0]) compared with those without asthma. Every additional chronic condition with asthma was associated with a greater likelihood of an asthma attack (PR = 1.1 [95% CI: 1.0-1.2]), all-cause emergency department visits (PR = 1.3 [95% CI: 1.1-1.5]), and missed school days (PR = 2.3 [95% CI: 1.7-3.2]).

CONCLUSIONS

Children and adolescents with asthma in the US who suffer from MCCs have increased asthma symptoms, missed school days, and all-cause emergency department visits. Further research on optimal management strategies for this group is needed.