1
|
Vazquez S, Berke C, Lu VM, Wu EM, Silva MA, Das A, Soldozy S, Dominguez JF, Wang S. Pediatric Patients with Intracranial Arteriovenous Malformations: Trends in Emergency Room Presentation. World Neurosurg 2024; 188:e297-e304. [PMID: 38796143 DOI: 10.1016/j.wneu.2024.05.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Pediatric intracranial arteriovenous malformation (AVM) patients are commonly admitted to the emergency room (ER). Increasing patient utilization of the ER has been associated with healthcare disparities and a trend of decreased efficiency. The aim of this study was to evaluate the trends of pediatric AVM ER admissions over recent years and identify factors associated with health care resource utilization and outcomes. METHODS The 2016-2019 National Inpatient Sample was queried for patients under the age of 18 admitted with AVM. Cases of admission through the ER were identified. Demographic and severity factors associated with ER admission were explored using comparative and regression statistics. RESULTS Of 3875 pediatric patients with AVM admitted between 2016 and 2019, 1280 (33.0%) were admitted via the ER. Patients admitted via the ER were more likely to be in the lowest median income category (P < 0.001), on Medicaid insurance (P = 0.008), or in the South (P < 0.001) than patients admitted otherwise. There was increased severity and increased rates of intracranial hemorrhage (ICH) in patients admitted via the ER (P < 0.001). Finally, there were increasing trends in ER admissions and ICH throughout the years. CONCLUSIONS ER admission of pediatric AVM patients with ICH is increasing and is associated with a distinct socioeconomic profile and increased healthcare resource utilization. These findings may reflect decreased access to more advanced diagnostic modalities, primary care, and other important resources. Identifying populations with barriers to care is likely an important component of policy aimed at decreasing the risk of severe disease presentation.
Collapse
Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, New York, USA.
| | - Chandler Berke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eva M Wu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael A Silva
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ankita Das
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Shelly Wang
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| |
Collapse
|
2
|
Seag DEM, Cervantes PE, Narcisse I, Wiener E, Tay ET, Knapp K, Horwitz SM. Implementation Barriers Encountered During a Universal Suicide Screening Program in Pediatric Emergency Departments. Pediatr Emerg Care 2024:00006565-990000000-00467. [PMID: 38748454 DOI: 10.1097/pec.0000000000003221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs. METHODS Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported. RESULTS Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening. CONCLUSIONS Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.
Collapse
Affiliation(s)
- Dana E M Seag
- From the Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY
| | - Paige E Cervantes
- Department of Psychiatry, Virginia Commonwealth University Health, Richmond, VA
| | - Iriane Narcisse
- From the Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY
| | | | | | - Katrina Knapp
- Pediatric Emergency Department, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY
| | - Sarah McCue Horwitz
- From the Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Ziogas IA, Roach JP, Acker SN, Corkum KS, Diaz-Miron JL, Kulungowski AM, Gosain A, Hills-Dunlap JL. Association of Sociodemographic Factors with Surgical Management of Hepatoblastoma and Hepatocellular Carcinoma in Children. J Pediatr 2024; 269:113963. [PMID: 38369237 DOI: 10.1016/j.jpeds.2024.113963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/12/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To evaluate for disparities in surgical care among US children with hepatoblastoma (HB) and hepatocellular carcinoma (HCC). STUDY DESIGN In this retrospective National Cancer Database study (2004-2015), children aged <18 years with HB or HCC were included. Multivariable mixed-effects logistic regression was used to evaluate the association of sociodemographic factors (age, sex, race and ethnicity, insurance status, income, proximity to treating hospital) with the odds of undergoing surgical treatment after adjusting for disease-related factors (tumor size, metastasis, comorbidities) and hospital-level effects. Subgroup analyses by tumor histology were performed. RESULTS A total of 811 children were included (HB: 80.9%; HCC: 19.1%), of which 610 (75.2%) underwent surgical treatment. Following adjustment, decreased odds of undergoing surgical treatment were associated with Black race (OR: 0.46 vs White, 95% CI [95% CI]: 0.26-0.80, P = .01), and having Medicaid (OR: 0.58 vs private, 95% CI: 0.38-0.88, P = .01) or no insurance (OR: 0.33 vs private, 95% CI: 0.13-0.80, P = .02). In children with HB, Black race was associated with decreased odds of undergoing surgical treatment (OR: 0.47 vs White, 95% CI: 0.25-0.89, P = .02). In children with HCC, Medicaid (OR: 0.10 vs private, 95% CI: 0.03-0.35, P < .001), or no insurance status (OR: 0.10 vs private, 95% CI: 0.01-0.83, P = .03) were associated with decreased odds of undergoing surgical treatment. Other than metastatic disease, no additional factors were associated with likelihood of surgical treatment in any group. CONCLUSIONS Black race and having Medicaid or no insurance are independently associated with decreased odds of surgical treatment in children with HB and HCC, respectively. These children may be less likely to undergo curative surgery for their liver cancer.
Collapse
Affiliation(s)
- Ioannis A Ziogas
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jonathan P Roach
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Kristine S Corkum
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jose L Diaz-Miron
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ankush Gosain
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jonathan L Hills-Dunlap
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO.
| |
Collapse
|
5
|
Benítez TM, Kim YJ, Kong L, Wang L, Chung KC. Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair. Surgery 2023; 174:1281-1289. [PMID: 37586892 DOI: 10.1016/j.surg.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. METHODS This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. RESULTS 16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84). CONCLUSION Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.
Collapse
Affiliation(s)
- Trista M Benítez
- University of Michigan Medical School, Ann Arbor, MI; Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. https://www.twitter.com/benitez_trista
| | - You J Kim
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Rush University Medical College, Chicago, IL. https://www.twitter.com/kim_youj
| | - Lingxuan Kong
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
| |
Collapse
|
6
|
Sborov KD, Haruno LS, Raszka S, Poon SC. Racial and Ethnic Disparities in Pediatric Musculoskeletal Care. Curr Rev Musculoskelet Med 2023; 16:488-492. [PMID: 37548870 PMCID: PMC10497489 DOI: 10.1007/s12178-023-09860-0] [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] [Accepted: 07/23/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE OF REVIEW This article provides a review of recent published research studying racial, ethnic, and socioeconomic disparities in pediatric musculoskeletal care. RECENT FINDINGS Disparities in pediatric musculoskeletal care are demonstrated in two general realms: access to care and health outcomes. Though initiatives have been proposed or enacted to address disparities, underrepresented minorities and patients from lower socioeconomic statuses continue to face barriers across the spectrum of orthopedic care and poorer ultimate outcomes after both non-operative and operative management. Minority pediatric patients and those from lower socioeconomic statuses experience delays across the spectrum of orthopedic care for both urgent and non-urgent conditions. They wait longer between injury date and initial orthopedic evaluation, longer to receipt of diagnostic imaging, and longer to ultimate treatment than their counterparts. When finally able to obtain musculoskeletal care and treatment, they are at higher risk of poor in-hospital outcomes and inpatient complications, worse patient reported outcomes, and suboptimal pain management. In the outpatient setting, they receive less physical therapy and follow-up clinic visits, resulting in greater stiffness and strength deficits, and are ultimately less likely to meet return to sport criteria.
Collapse
Affiliation(s)
- Katherine D. Sborov
- Department of Orthopedic Surgery, Cedars Sinai Medical Center, Los Angeles, USA
| | - Lee S. Haruno
- Department of Orthopedic Surgery, Cedars Sinai Medical Center, Los Angeles, USA
| | - Samuel Raszka
- Department of Orthopedic Surgery, Cedars Sinai Medical Center, Los Angeles, USA
| | - Selina C. Poon
- Shriners Children’s Southern California, 909 S. Fair Oaks Ave, Pasadena, CA 91105 USA
| |
Collapse
|
7
|
Bajaj MA, Wilcox HC, Adams LB, Berman AL, Cwik M, Kitchen C, Miller L, Nestadt PS, Slade EP, Haroz EE. Demographic predictors of emergency service utilization patterns in youth at risk of suicide. Suicide Life Threat Behav 2023; 53:702-712. [PMID: 37431982 PMCID: PMC10916713 DOI: 10.1111/sltb.12975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/08/2023] [Accepted: 06/23/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors). METHODS Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period. RESULTS Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission. CONCLUSIONS Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services.
Collapse
Affiliation(s)
- Mira A. Bajaj
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Holly C. Wilcox
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Leslie B. Adams
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alan L. Berman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mary Cwik
- Department of International Health, Center for American Indian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Christopher Kitchen
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Leslie Miller
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Paul S. Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eric P. Slade
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily E. Haroz
- Department of International Health, Center for American Indian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
8
|
Butler LR, Abbott E, Mengsteab P, Dominy CL, Poeran J, Allen AK, Ranade SC. Epidemiology of pediatric trauma and fractures during and beyond the COVID-19 pandemic. J Child Orthop 2023; 17:322-331. [PMID: 37560351 PMCID: PMC10285363 DOI: 10.1177/18632521231180161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE Previous literature has shown decreases in pediatric trauma during the COVID-19 outbreak, but few have analyzed beyond the peak of the pandemic. This study assesses the epidemiology of pediatric trauma cases in a high-volume teaching hospital in New York City before, during, and after the height of the COVID-19 pandemic. METHODS Institutional data on pediatric trauma orthopedic cases from January 1, 2018 to November 30, 2021 were extracted. The following time frames were studied: (1) April 1-June 22 in 2018 and 2019 (pre-pandemic), (2) April 1-June 22, 2020 (peak pandemic), and (3) April 1-June 22, 2021 (post-peak pandemic). Inferential statistics were used to compare patient and trauma characteristics. RESULTS Compared to the pre-pandemic cohort (n = 6770), the peak pandemic cohort (n = 828) had a greater proportion of fractures (p < 0.01) and had a significantly decreased overall traumas per week rate (p < 0.01) and fractures per week rate (p < 0.01). These decreased trauma (p < 0.01) and fracture rates (p < 0.01) persisted for the post-peak pandemic cohort (n = 2509). Spatial analysis identified zip code clusters throughout New York City with higher rates of emergency department presentation during the peak pandemic compared to pre-pandemic, and these areas aligned with lower-income neighborhoods. CONCLUSION During the peak of the pandemic, overall trauma and fracture volumes decreased, the types of prevalent injuries changed, and neighborhoods of different economic resources were variably impacted. These trends have mostly persisted for 12 months post-peak pandemic. This longitudinal analysis helps inform and improve long-term critical care and public health resource allocation for the future. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Liam R Butler
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Erin Abbott
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Paulos Mengsteab
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Calista L Dominy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jashvant Poeran
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Abigail K Allen
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Sheena C Ranade
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| |
Collapse
|
9
|
Toraman Turk S, Merianos AL, Stone L, Schnadower D, Bouvay K, Mahabee-Gittens EM. "I Don't Want My Child to Be a Guinea Pig": Reasons for Non-Participation in a Parental Tobacco Cessation Trial in the Pediatric Emergency Department Setting. TOXICS 2023; 11:655. [PMID: 37624161 PMCID: PMC10458252 DOI: 10.3390/toxics11080655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/28/2023] [Accepted: 07/18/2023] [Indexed: 08/26/2023]
Abstract
(1) Background: Pediatric emergency department (PED) settings are opportune venues in which to recruit parental smokers into tobacco cessation interventions. However, the barriers associated with parents' participation in PED-based cessation trials are unknown. The objective was to explore parents' reasons for non-participation in a PED-based tobacco cessation trial. (2) Methods: We employed the framework method and conducted a qualitative data analysis of parental smokers who were eligible to participate in a PED-based tobacco cessation trial and did not choose to participate (n = 371). (3) Results: Two main themes emerged about reasons for non-participation: (a) Not interested in participating in a research study, and (b) concerns specific to the study. Parents had various reasons for not participating in the cessation trial including not being interested in quitting, parents' health and well-being, parents' beliefs about research, and time required for the study and follow-up visits. (4) Conclusion: General disinterest and specific study-related concerns were touted as reasons for non-participation in a PED-based tobacco cessation trial. Given the potential reductions in tobacco-related morbidity to both parents and children that tobacco control interventions can facilitate, future tobacco interventions should consider alterations in study design and recruitment strategies to encourage all eligible parental smokers to participate.
Collapse
Affiliation(s)
- Sinem Toraman Turk
- Department of Health Policy and Management, Global Health Leadership Initiative, Yale University, 60 College Street, New Haven, CT 06520, USA
| | - Ashley L. Merianos
- School of Human Services, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Lara Stone
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229, USA; (L.S.); (E.M.M.-G.)
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229, USA; (L.S.); (E.M.M.-G.)
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Kamali Bouvay
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229, USA; (L.S.); (E.M.M.-G.)
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - E. Melinda Mahabee-Gittens
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229, USA; (L.S.); (E.M.M.-G.)
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| |
Collapse
|
10
|
Forster BL, Thomas F, Arnold SR, Snider MA. Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations. Pediatr Emerg Care 2023; 39:524-529. [PMID: 36728409 DOI: 10.1097/pec.0000000000002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission. OBJECTIVE To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions. METHODS Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration. RESULTS A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95). CONCLUSIONS Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.
Collapse
Affiliation(s)
- Brian L Forster
- From the Division of Emergency Services, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventative Medicine, The University of Tennessee Health Science Center
| | - Sandra R Arnold
- Division of Infectious Diseases, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN
| | - Mark A Snider
- From the Division of Emergency Services, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital
| |
Collapse
|
11
|
Pergeline J, Rivière S, Rey S, Fresson J, Rachas A, Tuppin P. Social deprivation and the use of healthcare services over one year by children less than 18 years of age in 2018: A French nationwide observational study. PLoS One 2023; 18:e0285467. [PMID: 37224152 DOI: 10.1371/journal.pone.0285467] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 03/07/2023] [Indexed: 05/26/2023] Open
Abstract
This study aimed to describe the health status of children and how social deprivation affects their use of healthcare services and mortality. Children living in mainland France were selected from the national health data system (SNDS) on their date of birth or birthday in 2018 (< 18 years) and followed for one year. Information included data on healthcare reimbursements, long-term chronic diseases (LTDs) eligible for 100% reimbursement, geographic deprivation index (FDep) by quintile (Q5 most disadvantaged), and individual complementary universal insurance (CMUc) status, granted to households with an annual income below the French poverty level. The number of children who had at least one annual visit or hospital admission was compared using the ratio of geographic deprivation (rQ5/Q1) and CMUc (rCMUc/Not) after gender and age-standardization. Over 13 million children were included; 17.5% had CMUc, with an increase across quintiles (rQ5/Q1 = 3.5) and 4.0% a LTD (rQ5/Q1 = 1.44). The 10 most frequent LTDs (6 psychiatric) were more common as the deprivation increased. Visits to general practitioners (GPs) were similar (≈84%) for each FDep quintile and the density of GPs similar. The density decreased with increasing deprivation for specialists and visits: paediatricians (rQ5/Q1 = 0.46) and psychiatrists (rQ5/Q1 = 0.26). Dentist visits also decreased (rQ5/Q1 = 0.86) and deprived children were more often hospitalised for dental caries (rQ5/Q1 = 2.17, 2.1% vs 0.7%). Emergency department (ED) visits increased with deprivation (rCMUc/Not = 1.35, 30% vs 22%) but 50% of CMUc children lived in a municipality with an ED vs. 25% without. Approximately 9% of children were admitted for a short stay and 4.5% for a stay > 1 night (rQ5/Q1 = 1.44). Psychiatric hospitalization was more frequent for children with CMUc (rCMUc/Not = 3.5, 0.7% vs 0.2%). Higher mortality was observed for deprived children < 18 years (rQ5/Q1 = 1.59). Our results show a lower use of pediatricians, other specialists, and dentists among deprived children that may be due, in part, to an insufficient supply of care in their area of residence. These results have been used to recommend optimization and specifically adapted individual or area-wide policies on the use of healthcare services, their density, and activities.
Collapse
Affiliation(s)
- Jeanne Pergeline
- Caisse Nationale de l'assurance Maladie (Cnam), Direction de la Stratégie des études et des Statistiques, Paris, France
| | - Sébastien Rivière
- Caisse Nationale de l'assurance Maladie (Cnam), Direction de la Stratégie des études et des Statistiques, Paris, France
| | - Sylvie Rey
- Direction de la Recherche, des études, de l'évaluation et des Statistiques (Drees), Paris, France
| | - Jeanne Fresson
- Direction de la Recherche, des études, de l'évaluation et des Statistiques (Drees), Paris, France
| | - Antoine Rachas
- Caisse Nationale de l'assurance Maladie (Cnam), Direction de la Stratégie des études et des Statistiques, Paris, France
| | - Philippe Tuppin
- Caisse Nationale de l'assurance Maladie (Cnam), Direction de la Stratégie des études et des Statistiques, Paris, France
| |
Collapse
|
12
|
Pergeline J, Lesuffleur T, Rey S, Fresson J, Rachas A, Tuppin P. Long-term chronic diseases and 1-year use of healthcare services by children under 18 years of age during 2018-2019: A French nationwide observational study. Arch Pediatr 2023; 30:48-58. [PMID: 36481163 DOI: 10.1016/j.arcped.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 11/02/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Among children younger than 18 years, the prevalence of long-term chronic diseases (LTDs) is not well known in France, nor the frequency of the use of healthcare services. This nationwide observational study focused on both topics over a 1-year period following the birth or birthday of French children in 2018 and compared the LTD status and use of healthcare. MATERIALS AND METHODS We selected children living in mainland France from the national health data system (SNDS). It includes data concerning the LTD status, which guarantees 100% reimbursement for related healthcare expenditures. We calculated the median and interquartile range (IQR) for the prevalence of LTDs and the rate of children using healthcare services at least once during the year. RESULTS We included 13.211 million children (51.2% boys), of whom 4% had at least one LTD (boys: 4.6%, girls: 3.3%). Mental and behavioral disorders were the most frequent cause (1.6%). At least one visit to a general practitioner (GP) or pediatrician was found for 88% of children (median: 3, IQR: 2-6): 98% for children under 1 year of age and 81% for children aged 14-17 years. A pediatrician was visited by 17% of children, another specialist by 39%, a dentist by 37%, with peaks of about 60% at the ages of 6, 9, and 12 years; 8% visited a nurse and 7% visited a physiotherapist. At least one emergency department visit was recorded for 24% of children (42% <1 year) and one short-stay hospitalization (SSH) for 9%. Regional variations were observed. Children with LTDs more frequently used all services, such as specialist visits (50% vs. 40%), ED visits (32% vs. 23%), SSHs (26% vs. 8% and 15% vs. 4.0% for one night or more), and psychiatric hospital admissions (5% vs. 0.1%). CONCLUSION Most children saw a GP or pediatrician during the year and children with an LTD showed more frequent use. Nevertheless, outpatient visits appeared to be underutilized with respect to recommendations or free-of-charge prevention visits, such as for dentists. More detailed studies are required to identify factors associated with the use of healthcare services in France, for example, studies including the deprivation index and regional variations.
Collapse
Affiliation(s)
- J Pergeline
- Caisse Nationale de l'Assurance Maladie, Direction de la Stratégie des Études et des Statistiques, 26-50, Avenue du Professeur André Lemierre 20, Paris F-75986 CEDEX, France
| | - T Lesuffleur
- Caisse Nationale de l'Assurance Maladie, Direction de la Stratégie des Études et des Statistiques, 26-50, Avenue du Professeur André Lemierre 20, Paris F-75986 CEDEX, France
| | - S Rey
- Direction de la recherche, des études, de l'évaluation et des statistiques (Drees), Paris 75015, France
| | - J Fresson
- Direction de la recherche, des études, de l'évaluation et des statistiques (Drees), Paris 75015, France
| | - A Rachas
- Caisse Nationale de l'Assurance Maladie, Direction de la Stratégie des Études et des Statistiques, 26-50, Avenue du Professeur André Lemierre 20, Paris F-75986 CEDEX, France
| | - P Tuppin
- Caisse Nationale de l'Assurance Maladie, Direction de la Stratégie des Études et des Statistiques, 26-50, Avenue du Professeur André Lemierre 20, Paris F-75986 CEDEX, France.
| |
Collapse
|
13
|
Thomas-Smith S, Klein E, Strelitz B, Jensen J, Parker E, Richardson L, McCarty C, Shafii T. Electronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial. West J Emerg Med 2022; 23:931-938. [DOI: 10.5811/westjem.2022.7.55755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/19/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction: In this study we aimed to assess the impact of an electronic health assessment with individualized feedback for risk behaviors in adolescents seeking care in a pediatric emergency department (ED).
Methods: We conducted a randomized control trial using a tablet-based screening program with a study population of adolescents in a busy pediatric ED. The intervention group received the screening program with individualized feedback. The control group received the screening program without feedback. All participants received one-day and three-month follow-up surveys to assess behaviors and attitudes toward health behaviors.
Results: A total of 296 subjects were enrolled and randomized. There was no difference in changes in risky behaviors between the control and experimental groups. A higher proportion of participants in the intervention groups reported that the screener changed the way they thought about their health at one-day follow-up (27.0%, 36/133) compared to the control group (15.5%, 20/129, P = .02).
Conclusion: This study successfully tested a multivariable electronic health screener in a real-world setting of a busy pediatric ED. The tool did not significantly change risky health behaviors in the adolescent population screened. However, our finding that the intervention changed adolescents’ perceptions of their health opens a door to the continued development of electronic interventions to screen for and target risk behaviors in adolescents in the ED setting.
Collapse
Affiliation(s)
- Siobhan Thomas-Smith
- University of Washington, Seattle Children’s Hospital, Department of Pediatrics, Division of Emergency Medicine, Seattle, Washington
| | - Eileen Klein
- University of Washington, Seattle Children’s Hospital, Department of Pediatrics, Division of Emergency Medicine, Seattle, Washington
| | - Bonnie Strelitz
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Jennifer Jensen
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Elizabeth Parker
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Laura Richardson
- University of Washington School of Medicine, Department of Pediatrics, Division of Adolescent Medicine, Seattle, Washington
| | - Carolyn McCarty
- University of Washington School of Medicine, Department of Pediatrics, Division of Adolescent Medicine, Seattle, Washington
| | - Taraneh Shafii
- University of Washington School of Medicine, Department of Pediatrics, Division of Adolescent Medicine, Seattle, Washington
| |
Collapse
|
14
|
Ahearn MA, Stephens JR, Zwemer EK, Hall M, Ahuja A, Chatterjee A, Coletti H, Fuchs J, Lewis E, Liles EA, Reade E, Sutton AG, Sweeney A, Weinberg S, Harrison WN. Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes. Hosp Pediatr 2022; 12:969-980. [PMID: 36285567 DOI: 10.1542/hpeds.2022-006627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization. METHODS Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement. RESULTS We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year. CONCLUSIONS Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.
Collapse
Affiliation(s)
- M Alex Ahearn
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John R Stephens
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Eric K Zwemer
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matt Hall
- Department of Analytics, Children's Hospital Association, Overland Park, Kansas
| | - Arshiya Ahuja
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ashmita Chatterjee
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hannah Coletti
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jennifer Fuchs
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emilee Lewis
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - E Allen Liles
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Reade
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ashley G Sutton
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Alison Sweeney
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Steven Weinberg
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Wade N Harrison
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
15
|
Harrison WN, Ritter VS, Flower KB, Seashore CJ, McLaurin-Jiang S. The Association Between Routine Car Seat Screening and Subsequent Health Care Utilization. Hosp Pediatr 2022; 12:913-922. [PMID: 36189493 PMCID: PMC9647635 DOI: 10.1542/hpeds.2021-006509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The American Academy of Pediatrics recommends preterm newborns undergo car seat tolerance screening (CSTS) before discharge despite limited evidence supporting the practice. We examined subsequent health care utilization in screened and unscreened late preterm and low birth weight newborns. METHODS This observational study included late preterm (34-36 weeks) and term low birth weight (<2268 g) newborns born between 2014 and 2018 at 4 hospitals with policies recommending CSTS for these infants. Birth hospitalization length of stay (LOS) in addition to 30-day hospital revisits and brief resolving unexplained events were examined. Unadjusted and adjusted rates were compared among 3 groups: not screened, pass, and fail. RESULTS Of 5222 newborns, 3163 (61%) were discharged from the nursery and 2059 (39%) from the NICU or floor. Screening adherence was 91%, and 379 of 4728 (8%) screened newborns failed the initial screen. Compared with unscreened newborns, adjusted LOS was similar for newborns who passed the CSTS (+5.1 hours; -2.2-12.3) but significantly longer for those who failed (+16.1; 5.6-26.7). This differed by screening location: nursery = +12.6 (9.1-16.2) versus NICU/floor = +71.2 (28.3-114.1) hours. Hospital revisits did not significantly differ by group: not screened = 7.3% (reference), pass = 5.2% (aOR 0.79; 0.44-1.42), fail = 4.4% (aOR 0.65; 0.28-1.51). CONCLUSIONS Hospital adherence to CSTS recommendations was high, and failed screens were relatively common. Routine CSTS was not associated with reduced health care utilization and may prolong hospital LOS, particularly in the NICU/floor. Prospective trials are needed to evaluate this routine practice for otherwise low-risk infants.
Collapse
Affiliation(s)
- Wade N. Harrison
- Division of Hospital Medicine
- Cecil G. Sheps Center for Health Services Research
| | - Victor S. Ritter
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kori B. Flower
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Carl J. Seashore
- Division of Hospital Medicine
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Skyler McLaurin-Jiang
- Department of Pediatrics, Texas Tech University Health Sciences Center School of Medicine, Amarillo, Texas
| |
Collapse
|
16
|
Pianucci L, Longacre ML. Nonurgent Emergency Department Use by Pediatric Patients in the United States: A Systematic Literature Review. Pediatr Emerg Care 2022; 38:540-544. [PMID: 35580154 DOI: 10.1097/pec.0000000000002718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric use of the emergency department (ED) for nonurgent reasons is common in the United States. Patients with nonurgent conditions can receive more appropriate, cost-efficient care in other settings. We conducted a systematic literature review to understand the breadth of factors that contribute to use of the ED for nonurgent conditions by pediatric patients in the United States. METHODS The literature search was conducted according to the PRISMA guidelines for systematic reviews and was guided by the social-ecological model for synthesis of articles. Published articles were identified through a search of Academic Search Ultimate, Google Scholar, and PubMed. All articles were organized and managed using Endnote software and screened for eligibility criteria before full-text review. RESULTS The initial search yielded 679 articles with 530 articles remaining after the removal of duplicates. Of these, 31 articles were reviewed in full text with 19 remaining for the final analysis. All articles assessed individual-level factors, including parental perceptions of ED and health literacy. Additional findings of nonurgent use of the ED were shown to pertain to the organizational and public policy levels of the model, including primary care clinic and insurance characteristics. CONCLUSIONS The findings of this review suggest tailored interventions to address parents'/caregivers' ED perceptions and health literacy in addition to access (ie, public policy).
Collapse
Affiliation(s)
- Lauren Pianucci
- From the Department of Public Health, Arcadia University, Glenside, PA
| | | |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Nonurgent Visits to the Pediatric Emergency Department before and during the First Peak of the COVID-19 Pandemic. Int J Pediatr 2022; 2022:7580546. [PMID: 35242194 PMCID: PMC8886764 DOI: 10.1155/2022/7580546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/03/2022] [Indexed: 11/28/2022] Open
Abstract
Background Nonurgent visits in pediatric Emergency Departments are a growing burden. In order to find predictors for those nonurgent visits, we performed a retrospective analysis of unscheduled visits at the Pediatric Emergency Department of the University Hospital of Bonn, Germany, in the year 2017. Additionally, we compared these findings to unscheduled visits during the first peak of the worldwide pandemic of the Coronavirus disease 2019, to see if there would be an effect on nonurgent pediatric Emergency Department attendances. Methods For our retrospective cohort study, we analyzed more than 5.000 visits at the pediatric Emergency Department of the University Hospital of Bonn, Germany, before and during the first peak of the ongoing worldwide pandemic of the Coronavirus disease 2019, particularly with regard to their urgency. Data included gender, age, zip code, urgency, and preexisting conditions. Results Our study shows that more than half of unscheduled pediatric Emergency Department visits (69%) at the University Hospital in Bonn are for nonurgent reasons, with short living distance being a factor to present children to a pediatric Emergency Department, even with minor complaints. During the first peak of the pandemic of the Coronavirus disease 2019, nonurgent visits decreased significantly, potentially due to hesitation to attend a pediatric Emergency Department with minor issues, fearing an infection with SARS-CoV-2 at the hospital. Conclusion Many people use pediatric Emergency Departments for nonemergency complaints. In order to address the reasons for nonurgent visits to pediatric Emergency Departments and to prevent parents from doing so, further studies and targeted education concepts for parents are needed.
Collapse
|
20
|
Murray A, Fein J, Beulah B, Mollen C. Examination of Caregiver Social Factors and Its Influence on Low-Acuity Pediatric Emergency Department Utilization. Pediatr Emerg Care 2022; 38:e611-e617. [PMID: 33848096 DOI: 10.1097/pec.0000000000002426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Social factors, such as adverse childhood experiences (ACEs), often influence health care utilization. Our study explores the association between caregiver social factors and low-acuity pediatric emergency department (ED) utilization, with the hypothesis that caregivers with high ACE exposure may use ED services more frequently for low-acuity complaints. METHODS In this case-control study, we performed surveys of caregivers with children aged 1 to 12 years registered for care in our pediatric ED. We defined high utilizers (cases) as those children with ≥3 low-acuity visits in the previous year and low utilizers (controls) as having no prior low-acuity visits, exclusive of the current visit. We compared the proportion of high ACE exposure (≥4 ACEs) between both groups. RESULTS We enrolled 114 cases and 134 controls. We found no association between number of ACEs and odds of being a case or control (ED utilization). Demographics were significantly different between the 2 groups (ie, caregiver age, race, education, and household income); caregiver ACE exposure was high in both groups (20.2% cases vs 29.1% controls with [≥4 ACEs]). CONCLUSIONS Although we did not find an association between caregiver ACEs and frequent low-acuity pediatric ED utilization, our data shed light on the overall prevalence of caregiver ACEs in families that seek care in our pediatric ED, even for the first time. Our findings emphasize the risk of conscious bias that can lead to inaccuracy: assuming that it is only high utilizers who experience social stressors. Future work should explore the contribution of structural inequities that influence caretakers' decisions to seek care for their children for low-acuity complaints, and consider types of interventions that could address and mitigate these inequities.
Collapse
Affiliation(s)
| | | | - Brianna Beulah
- Center for Violence Prevention, Children's Hospital of Philadelphia, Philadelphia, PA
| | | |
Collapse
|
21
|
Pickett ML, Goyal MK, Chernick LS. Time to Address Inequities in Chlamydia Screening Among Adolescents. Am J Public Health 2022; 112:7-8. [PMID: 34936407 PMCID: PMC8713601 DOI: 10.2105/ajph.2021.306609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Michelle L Pickett
- Michelle L. Pickett is with the Department of Pediatrics, Medical College of Wisconsin, Milwaukee. Monika K. Goyal is with the Department of Pediatrics and Emergency Medicine, Children's National Hospital, George Washington University, Washington, DC. Lauren S. Chernick is with the Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY
| | - Monika K Goyal
- Michelle L. Pickett is with the Department of Pediatrics, Medical College of Wisconsin, Milwaukee. Monika K. Goyal is with the Department of Pediatrics and Emergency Medicine, Children's National Hospital, George Washington University, Washington, DC. Lauren S. Chernick is with the Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY
| | - Lauren S Chernick
- Michelle L. Pickett is with the Department of Pediatrics, Medical College of Wisconsin, Milwaukee. Monika K. Goyal is with the Department of Pediatrics and Emergency Medicine, Children's National Hospital, George Washington University, Washington, DC. Lauren S. Chernick is with the Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
22
|
Bernstein AS, Sun S, Weinberger KR, Spangler KR, Sheffield PE, Wellenius GA. Warm Season and Emergency Department Visits to U.S. Children's Hospitals. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:17001. [PMID: 35044241 PMCID: PMC8767980 DOI: 10.1289/ehp8083] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Extreme heat exposures are increasing with climate change. Health effects are well documented in adults, but the risks to children are not well characterized. OBJECTIVES We estimated the association between warm season (May to September) temperatures and cause-specific emergency department (ED) visits among U.S. children and adolescents. METHODS This multicenter time-series study leveraged administrative data on 3.8 million ED visits by children and adolescents ≤18 years of age to the EDs of 47 U.S. children's hospitals from May to September from 2016 to 2018. Daily maximum ambient temperature was estimated in the county of the hospital using a spatiotemporal model. We used distributed-lag nonlinear models with a quasi-Poisson distribution to estimate the association between daily maximum temperature and the relative risk (RR) of ED visits, adjusting for temporal trends. We then used a random-effects meta-analytic model to estimate the overall cumulative association. RESULTS Extreme heat was associated with an RR of all-cause ED visits of 1.17 (95% CI: 1.12, 1.21) relative to hospital-specific minimum morbidity temperature. Associations were more pronounced for ED visits due to heat-related illness including dehydration and electrolyte disorders (RR= 1.83; 95% CI: 1.31, 2.57), bacterial enteritis (1.35; 95% CI: 1.02, 1.79), and otitis media and externa (1.30; 95% CI: 1.11, 1.52). Taken together, temperatures above the minimum morbidity temperature accounted for an estimated 11.8% [95% empirical 95% confidence interval (eCI): 9.9%, 13.3%] of warm season ED visits for any cause and 31.0% (95% eCI: 17.9%, 36.5%) of ED visits for heat-related illnesses. CONCLUSION During the warm season, days with higher temperatures were associated with higher rates of visits to children's hospital EDs. Higher ambient temperatures may contribute to a significant proportion of ED visits among U.S. children and adolescents. https://doi.org/10.1289/EHP8083.
Collapse
Affiliation(s)
- Aaron S. Bernstein
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Center for Climate, Health, and the Global Environment, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Shengzhi Sun
- Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kate R. Weinberger
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith R. Spangler
- Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Perry E. Sheffield
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Gregory A. Wellenius
- Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Cohen JS, Berkowitz D, Nosker L, Shaukat H, Kim D, Koutroulis I, Breslin KA. Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits. Pediatr Emerg Care 2022; 38:e417-e421. [PMID: 33273428 DOI: 10.1097/pec.0000000000002312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pediatric patients account for a disproportionate number of low-acuity emergency department (ED) visits. The aim of this study is to describe pediatric patient and visit characteristics for high-frequency users for low-acuity visits. METHODS This was a retrospective cohort study of children presenting to a tertiary care pediatric ED and an affiliated community ED, over a 2-year period, with at least 10 low-acuity visits. Twenty patients with the highest number of visits were classified as "superusers." We analyzed patient data from the larger sample of high-frequency users and visit specific data from superuser visits. IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL) was used to perform descriptive statistics and to summarize demographic and visit specific variables. RESULTS We identified 181 high-frequency users with a mean number of visits of 14.3 ± 4.3 and a subpopulation of 20 superusers accounting for 434 visits. The majority of high-frequency users (89%) identified as African American and had public insurance (96.1%). Many patients received primary care affiliated with the home institution. In the first year of the study, 50.3% of high-frequency users were infants younger than 1 year at the index visit and 47.4% of superusers were infants at the index visit.Superuser visits were evenly distributed among seasons and the majority of visits occurred during the weekdays (70.7%). The majority of visits were for medical complaints (86.6%) and almost half (47.6%) resulted in some testing (24.9%) or treatment (30.6%); however, only 1.4% resulted in hospital admission. CONCLUSIONS In our sample, most high-frequency low-acuity ED patients were infants, African American and have public insurance. Many are seen during clinic hours and are paneled at affiliated clinics. Among superusers, the majority of the visits did not require any testing, intervention, or treatment.
Collapse
Affiliation(s)
| | | | - Lois Nosker
- From the Division of Emergency Medicine, Children's National Health System
| | | | - Dana Kim
- From the Division of Emergency Medicine, Children's National Health System
| | | | | |
Collapse
|
24
|
Iorember FM, Bamgbola OF. Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults. Front Pediatr 2022; 10:833611. [PMID: 35450110 PMCID: PMC9016185 DOI: 10.3389/fped.2022.833611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.
Collapse
Affiliation(s)
- Franca M Iorember
- Division of Pediatric Nephrology, Baylor College of Medicine, Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Oluwatoyin F Bamgbola
- Division of Pediatric Nephrology, SUNY Downstate Medical Center, Brooklyn, NY, United States
| |
Collapse
|
25
|
Elango S, Whitmire R, Kim J, Berhane Z, Davis R, Turchi RM. Family Experience of Caregiver Burden and Health Care Usage in a Statewide Medical Home Program. Acad Pediatr 2022; 22:116-124. [PMID: 34280478 DOI: 10.1016/j.acap.2021.07.010] [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: 09/25/2020] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To evaluate family-reported caregiver experiences and health care utilization of patients enrolled in the Pennsylvania Medical Home Program (PA-MHP) statewide practice network and compare results to PA-MHP practices' Medical Home Index (MHI) scores. We hypothesized families enrolled in higher-scoring patient-and-family-centered medical homes (PCMH) on completed MHIs would report decreased caregiver burden and improved health care utilization. METHODS We analyzed surveys completed by families receiving care coordination services in PA-MHP's network and each practice's mean MHI score. A total of 3221 caregivers completed surveys evaluating hours spent coordinating care/week, missed school/workdays, sick visits, and emergency department (ED) visits. A total of 222 providers from 54 participating PA-MHP practices completed the nationally recognized MHI. Family/practice demographics were collected. We developed multivariate logistic regression models assessing independent associations among family survey outcomes and corresponding practices' MHI scores. RESULTS Families enrolled in high-scoring PCMHs had decreased odds of spending >1 h/wk coordinating care (odds ratio [OR] 0.82, adjusted OR [aOR]: 0.70, 95% confidence interval [CI] 0.55-0.90), missing workdays in the past 6 months (OR 0.82, aOR: 0.72, 95% CI 0.69-0.97), and ED visits in the past 12 months (OR 0.83, aOR: 0.81, 95% CI 0.65-0.99) in comparison to families enrolled in lower-scoring PCMHs. Families enrolled in higher-scoring PCMHs did not report fewer sick visits despite fewer ED visits, indicating more appropriate health care utilization. High-scoring PCMHs had lower percentages of publicly insured and low-income children. CONCLUSIONS Higher-scoring PCMHs are associated with decreased caregiver burden and improved health care utilization across diverse PA practices. Future studies should evaluate interventions uniformly improving PCMH quality and equity.
Collapse
Affiliation(s)
- Suratha Elango
- Department of Pediatrics, Baylor College of Medicine (S Elango), Houston, Tex
| | - Rebecca Whitmire
- Department of Pediatrics, St. Christopher's Hospital for Children (R Whitmire and RM Turchi), Philadelphia, Pa; Drexel University, Drexel University College of Medicine (R Whitmire and RM Turchi), Philadelphia, Pa; Drexel University, Dornsife School of Public Health (R Whitmire, J Kim, Z Berhane, R Davis, and RM Turchi), Philadelphia, Pa
| | - John Kim
- Drexel University, Dornsife School of Public Health (R Whitmire, J Kim, Z Berhane, R Davis, and RM Turchi), Philadelphia, Pa
| | - Zekarias Berhane
- Drexel University, Dornsife School of Public Health (R Whitmire, J Kim, Z Berhane, R Davis, and RM Turchi), Philadelphia, Pa
| | - Renee Davis
- Drexel University, Dornsife School of Public Health (R Whitmire, J Kim, Z Berhane, R Davis, and RM Turchi), Philadelphia, Pa
| | - Renee M Turchi
- Department of Pediatrics, St. Christopher's Hospital for Children (R Whitmire and RM Turchi), Philadelphia, Pa; Drexel University, Drexel University College of Medicine (R Whitmire and RM Turchi), Philadelphia, Pa; Drexel University, Dornsife School of Public Health (R Whitmire, J Kim, Z Berhane, R Davis, and RM Turchi), Philadelphia, Pa.
| |
Collapse
|
26
|
Goyal MK, Richardson T, Masonbrink A, Reed JL, Alpern ER, Hall M, Neuman MI. Reliance on Acute Care Settings for Health Care Utilization: A Comparison of Adolescents With Younger Children. Pediatr Emerg Care 2021; 37:e1128-e1132. [PMID: 32776762 PMCID: PMC7775320 DOI: 10.1097/pec.0000000000001924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Because a goal of the Affordable Care Act was to increase preventive care and reduce high-cost care, the objective of this study was to evaluate current health care use and reliance on acute care settings among Medicaid-enrolled children. METHODS This was a retrospective cohort study of the 2015 Truven Marketscan Medicaid claims database among children 0 to 21 years old with at least 11 months of continuous enrollment. We calculated adjusted probabilities of health care use (any health care use and ≥1 health maintenance visit) and high acute care reliance (ratio of emergency department or urgent care visits to all health care visits >0.33) by age and compared use between adolescents and younger children using multivariable logistic regression. RESULTS Of the 5,182,540 Medicaid-enrolled children, 18.9% had no health care visits and 47.3% had 1 or more health maintenance visit in 2015. Both health care use and health maintenance visits decreased with increasing age (P < 0.001). Compared with younger children (0-10 years old), adolescents were more likely to have no interaction with the health care system [adjusted odds ratio (aOR), 2.20; 95% confidence interval (CI), 2.19-2.21] and less likely to have health maintenance visits (aOR, 0.40; 0.39-0.40). High acute care reliance was associated with increasing age, with adolescents having greater odds of high acute care reliance (aOR, 1.08; 1.08-1.09). CONCLUSIONS Medicaid-enrolled adolescents have low rates of health care use and have high reliance on acute care settings. Further investigation into adolescent-specific barriers to health maintenance care and drivers for acute care is warranted.
Collapse
Affiliation(s)
- Monika K. Goyal
- Department of Pediatrics, Children’s National Health System, The George Washington University, Washington, DC
| | | | - Abbey Masonbrink
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jennifer L. Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Elizabeth R. Alpern
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University, Chicago, IL
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS
| | - Mark I. Neuman
- Division of Pediatric Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
27
|
Wang JF, Young TK, Melnick LE, Orlow SJ, Oza VS. Topical corticosteroid use for atopic dermatitis in the pediatric emergency department. Pediatr Dermatol 2021; 38:1127-1131. [PMID: 33870556 DOI: 10.1111/pde.14606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 03/15/2021] [Accepted: 04/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES To investigate the evaluation and management of atopic dermatitis (AD) in the pediatric emergency department (PED). METHODS This retrospective chart review was performed at the PED of a single institution and examined data from 2012 to 2017. Of 335 visits from patients 18 years and younger coded for AD, 167 visits with documented findings that supported a diagnosis of AD according to guidelines from the American Academy of Dermatology were included. RESULTS The mean age of presentation was 6.3 years (standard deviation [SD]: 5.9). Of 11 patients with multiple visits, the mean between-visit interval was 31 days (SD: 41). Topical corticosteroids (TCSs) were not prescribed or recommended in 63/167 visits. In an additional 46/167 visits, over-the-counter topical hydrocortisone was recommended. Of prescribed TCS, the mean TCS class was 5.5 (SD: 1.9). 61/104 recommended or prescribed TCSs were weak (Class 7), the most likely used class (P < .001). Dermatology consultation was requested in 14/167 visits and was associated with higher rates of TCS prescriptions (13/14 vs 91/153, P = .018), a higher mean class of TCS prescribed (3.1 vs 5.9, P < .001), higher prescription rates of systemic antibiotics (8/14 vs 10/153, P < .001), and higher recommendation rates for emollient usage (10/14 vs 46/153, P = .005). CONCLUSIONS Most patients presenting to the PED for AD were either not prescribed a TCS or were prescribed a weak TCS, often one that is over-the-counter. While there may be a variety of explanations for these findings, it is possible they reveal a practice gap regarding AD management in the PED.
Collapse
Affiliation(s)
- Jason F Wang
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Trevor K Young
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Laura E Melnick
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Seth J Orlow
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA.,Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
| | - Vikash S Oza
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA.,Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
28
|
Radlicz C, Jackson K, Hautmann A, Shi J, Yang J. Influence of insurance type on rate and type of initial concussion-related medical visits among youth. BMC Public Health 2021; 21:1565. [PMID: 34407798 PMCID: PMC8375144 DOI: 10.1186/s12889-021-11586-y] [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] [Received: 10/26/2020] [Accepted: 08/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background A growing number of studies report increased concussion-related health care utilization in recent years, but factors impacting care-seeking behaviors among youth following a concussion are not well described. This study aimed to evaluate the influence of insurance type on the rate and type of initial concussion visits and the time from injury to the initial visit in youth. Methods We extracted and analyzed initial concussion-related medical visits for youth ages 10 to 17 from electronic health records. Patients must have visited Nationwide Children’s Hospital’s (NCH) concussion clinic at least once between 7/1/2012 and 12/31/2017. We evaluated the trends and patterns of initial concussion visits across the study period using regression analyses. Results Of 4955 unique concussion visits included, 60.1% were males, 80.5% were white, and 69.5% were paid by private insurance. Patients’ average age was 13.9 years (SD = 3.7). The rate of the initial concussion visits per 10,000 NCH visits was consistently higher in privately insured than publicly insured youth throughout the study period (P < .0001). Privately insured youth had greater odds of initial concussion visits to sports medicine clinics (AOR = 1.45, 95% CI = 1.20, 1.76) but lower odds of initial concussion visits to the ED/urgent care (AOR = 0.74, 95% CI = 0.60, 0.90) than publicly insured youth. Days from injury to initial concussion visit significantly decreased among both insurance types throughout the study (P < .0001), with a greater decrease observed in publicly insured than privately insured youth (P = .011). Conclusions Results on the differences in the rate, type, and time of initial concussion-related visits may help inform more efficient care of concussion among youth with different types of insurance.
Collapse
Affiliation(s)
- Chris Radlicz
- Center for Injury Research and Policy, Nationwide Children's Hospital, 700 Children's Drive, RBIII-WB5403, Columbus, OH, 43205, USA
| | - Kenneth Jackson
- Biostatistics Resource, Nationwide Children's Hospital, Columbus, OH, USA.,Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Amanda Hautmann
- Center for Injury Research and Policy, Nationwide Children's Hospital, 700 Children's Drive, RBIII-WB5403, Columbus, OH, 43205, USA
| | - Junxin Shi
- Center for Injury Research and Policy, Nationwide Children's Hospital, 700 Children's Drive, RBIII-WB5403, Columbus, OH, 43205, USA
| | - Jingzhen Yang
- Center for Injury Research and Policy, Nationwide Children's Hospital, 700 Children's Drive, RBIII-WB5403, Columbus, OH, 43205, USA. .,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA.
| |
Collapse
|
29
|
Variables Prevalent Among Early Unplanned Readmissions in Infants Following Congenital Heart Surgery. Pediatr Cardiol 2021; 42:1449-1456. [PMID: 33974090 DOI: 10.1007/s00246-021-02631-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
Medically complex children including infants undergoing cardiac surgery are at increased risk for hospital readmissions. Investigation of this population may reveal opportunities to optimize systems and coordination of care. A retrospective study of all infants undergoing cardiac surgery from 2015 through 2016 at a large tertiary institution who were readmitted within 1 year of discharge from cardiac surgical hospitalization was performed. Data specific to patient characteristics, surgical hospitalization, and readmission hospitalization are described. Unplanned readmissions within 1 year of hospital discharge were analyzed with Cox proportional hazard regression to identify factors associated with increased hazard for earlier unplanned readmission. Comparable to previous reports, 12% (78/658) of all surgical hospitalizations were associated with unplanned readmission within 30 days. Infectious etiology, followed by cardiac and gastrointestinal problems, was the most common reasons for unplanned 30-day readmission. Unplanned readmissions within 2 weeks of discharge were multifactorial and less commonly related to cardiac or surgical care. Primary nasogastric tube feeding at the time of discharge was the only significant risk factor for earlier unplanned readmission (p = 0.032) on multivariable analysis. Increased care coordination with particular attention to feeding and comorbidity management may be future targets to effectively mitigate readmissions and improve quality of care in this population.
Collapse
|
30
|
Zachrison KS, Boggs KM, Gao J, Camargo CA, Samuels-Kalow ME. Patient Insurance Status Is Associated With Care Received After Transfer Among Pediatric Patients in the Emergency Department. Acad Pediatr 2021; 21:877-884. [PMID: 33227534 PMCID: PMC9137436 DOI: 10.1016/j.acap.2020.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/10/2020] [Accepted: 11/14/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine whether frequency of interfacility transfer varied by insurance status among pediatric emergency department (ED) patients. Secondarily, we tested for an association between insurance status and odds of transfer with discharge from the second ED without observation or admission. METHODS We used the 2016 New York State ED and Inpatient Databases to identify all patients <18 years. ED and hospital characteristics were from American Hospital Association and National ED Inventory-USA. Among all ED patients, we calculated the proportion transferred stratified by insurance status (private, public, none). Among ED-to-ED transfers, we identified transfers without subsequent observation or admission, and used hierarchical logistic regression modeling (adjusting for patient and transferring ED/hospital characteristics) to determine whether insurance status was associated with odds of discharge from the second ED without observation or admission. RESULTS Of 1,303,575 pediatric ED visits, 6086 (0.5%) were transferred. Transfers were less frequent among patients with public or no insurance. Of 3801 ED-to-ED transfers, 1451 (38%) were without subsequent observation or admission. In bivariate and multivariable analysis, transferred patients with public and with no insurance were less likely to be discharged without observation or admission relative to privately insured patients. CONCLUSION Among ED-to-ED transfers, pediatric patients with public or without insurance were more often kept for observation or admission at the second hospital after transfer. Differences in disease acuity or in providers' perception of follow-up availability may play a role in explaining these patterns. This disparity merits further investigation.
Collapse
Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass.
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Jingya Gao
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | | |
Collapse
|
31
|
Chang L, Stewart AM, Monuteaux MC, Fleegler EW. Neighborhood Conditions and Recurrent Emergency Department Utilization by Children in the United States. J Pediatr 2021; 234:115-122.e1. [PMID: 33395566 DOI: 10.1016/j.jpeds.2020.12.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the associations of social and physical neighborhood conditions with recurrent emergency department (ED) utilization by children in the US. STUDY DESIGN This cross-sectional study was conducted with the National Survey of Children's Health from 2016 to 2018 to determine the associations of neighborhood characteristics of cohesion, safety, amenities, and detractors with the proportions of children aged 1-17 years with recurrent ED utilization, defined as 2 or more ED visits during the past 12 months. A multivariable regression model was used to determine the independent association of each neighborhood characteristic with recurrent ED utilization controlling for individual-level characteristics. RESULTS In this study of 98 711 children weighted to a population of 70 million nationally, children had significantly greater rates of recurrent ED utilization if they lived in neighborhoods that were not cohesive, were not safe, or had detractors present (all P < .001). With adjustment for individual-level covariates and the other neighborhood characteristics, only neighborhood detractors were independently associated with recurrent ED utilization (1 detractor: aOR 1.32, 95% CI 1.03-1.68; 2 or 3 detractors: aOR 1.37, 95% CI 1.04-1.81). CONCLUSIONS Among neighborhood characteristics, the presence of physical detractors such as rundown housing and vandalism was most strongly associated with recurrent ED utilization by children. Negative attributes of the built environment may be a potential target for neighborhood-level, place-based interventions to alleviate disparities in child healthcare utilization.
Collapse
Affiliation(s)
- Lawrence Chang
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston Medical Center, Boston, MA.
| | - Amanda M Stewart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
32
|
Ravi N, Gitz KM, Burton DR, Ray KN. Pediatric non-urgent emergency department visits and prior care-seeking at primary care. BMC Health Serv Res 2021; 21:466. [PMID: 34001093 PMCID: PMC8128083 DOI: 10.1186/s12913-021-06480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits. METHODS We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics. RESULTS Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit. CONCLUSIONS Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.
Collapse
Affiliation(s)
- Nithin Ravi
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA.
| | - Katherine M Gitz
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA
- Children's Hospital of Los Angeles Medical Group, Los Angeles, USA
| | - Danielle R Burton
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kristin N Ray
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
33
|
Merianos AL, Jandarov RA, Gordon JS, Lyons MS, Mahabee-Gittens EM. Healthcare resources attributable to child tobacco smoke exposure. PLoS One 2021; 16:e0247179. [PMID: 33621228 PMCID: PMC7901732 DOI: 10.1371/journal.pone.0247179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background Tobacco smoke exposure (TSE) places an economic toll on the U.S. healthcare system. There is a gap in the literature on pediatric emergency department (ED) and urgent care related healthcare costs and utilization specific to tobacco smoke-exposed patients. The objectives were to assess pediatric ED visits, urgent care visits and hospital admissions longitudinally, and baseline visit costs among tobacco smoke-exposed children (TSE group) relative to unexposed children (non-TSE group). Methods and findings We conducted a retrospective study using electronic medical records of 380 children ages 0–17 years in the TSE group compared to 1,140 in the non-TSE group propensity score matched via nearest neighbor search by child age, sex, race, and ethnicity. Linear and Poisson regression models were used. Overall, children had a mean of 0.19 (SE = 0.01) repeat visits within 30-days, and 0.69 (SE = 0.04) pediatric ED visits and 0.87 (SE = 0.03) urgent care visits over 12-months following their baseline visit. The percent of children with ≥ 1 urgent care visit was higher among the TSE group (52.4%) than the non-TSE group (45.1%, p = 0.01). Children in the TSE group (M = $1,136.97, SE = 76.44) had higher baseline pediatric ED visit costs than the non-TSE group (M = $1,018.96, SE = 125.51, p = 0.01). Overall, children had 0.08 (SE = 0.01) hospital admissions over 12-months, and the TSE group (M = 0.12, SE = 0.02) had higher mean admissions than the non-TSE group (M = 0.06, SE = 0.01, p = 0.02). The child TSE group was at 1.85 times increased risk of having hospital admissions (95% CI = 1.23, 2.79, p = 0.003) than the non-TSE group. Conclusions Tobacco smoke-exposed children had higher urgent care utilization and hospital admissions over 12-months, and higher pediatric ED costs at baseline. Pediatric ED visits, urgent care visits, and hospitalizations may be opportune times for initiating tobacco control interventions, which may result in reductions of preventable acute care visits.
Collapse
Affiliation(s)
- Ashley L. Merianos
- School of Human Services, University of Cincinnati, Cincinnati, Ohio, United States of America
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Roman A. Jandarov
- Department of Environmental and Public Health Sciences, Division of Biostatistics and Bioinformatics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Judith S. Gordon
- College of Nursing, The University of Arizona, Tucson, Arizona, United States of America
| | - Michael S. Lyons
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - E. Melinda Mahabee-Gittens
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Ray KN, Yahner KA, Bey J, Martin KC, Planey AM, Culyba AJ, Miller E. Understanding Variation In Nonurgent Pediatric Emergency Department Use In Communities With Concentrated Disadvantage. Health Aff (Millwood) 2021; 40:156-164. [PMID: 33400581 DOI: 10.1377/hlthaff.2020.00675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Children in communities with concentrated socioeconomic and structural disadvantage tend to have elevated rates of nonurgent visits to emergency departments (EDs). Using a spatial regression model of 264 census block groups in Pittsburgh, Pennsylvania, we investigated sociodemographic and structural factors associated with lower-than-expected ("low utilization") versus higher-than-expected ("high utilization") nonurgent ED visit rates among children in block groups with concentrated disadvantage. Compared with high-utilization block groups, low-utilization block groups had higher percentages of households with two adults, high school graduates, access to vehicles, sound housing quality, and owner-occupied housing. Notably, low-utilization block groups did not differ significantly from high-utilization block groups either in the percentage of households located within very close proximity to public transit or primary care or in children's health insurance coverage rates. Stakeholders wishing to reduce pediatric nonurgent ED visits among families in communities of concentrated disadvantage should consider strategies to mitigate financial, time, transportation, and health literacy constraints that may affect families' access to primary care.
Collapse
Affiliation(s)
- Kristin N Ray
- Kristin N. Ray is an associate professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, in Pittsburgh, Pennsylvania
| | - Kristin A Yahner
- Kristin A. Yahner is the General Academic Pediatrics Division data center coordinator, Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Jamil Bey
- Jamil Bey is the president and CEO of the UrbanKind Institute, in Pittsburgh, Pennsylvania
| | - Katherine C Martin
- Katherine C. Martin is a fourth-year medical student at the University of Pittsburgh School of Medicine
| | - Arrianna M Planey
- Arrianna M. Planey is an assistant professor in the Department of Health Policy and Management at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, in Chapel Hill, North Carolina
| | - Alison J Culyba
- Alison J. Culyba is an assistant professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh
| | - Elizabeth Miller
- Elizabeth Miller is a professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh
| |
Collapse
|
36
|
Ismail AF, Tarawah RA, Azzouni ZY, Alharbi LT, Altayyar RM. The relation between regular outpatient follow-up and frequency of emergency department visits in sickle cell pediatric patients. Saudi Med J 2020; 41:1324-1329. [PMID: 33294890 PMCID: PMC7841586 DOI: 10.15537/smj.2020.12.05585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives: To evaluate the relationship between the frequency of ED visits and outpatient department (OPD) follow-up in sickle cell disease (SCD) pediatric patients. Methods: A retrospective cohort study included 247 SCD pediatric patients between January 2016 and December 2018 at the Maternity and Children Hospital, Department of Pediatrics, Al Medinah Al Munawarah, Saudi Arabia. Data were extracted from electronic medical record system; patient demographics, medications, frequency of emergency department (ED) and OPD visits. Pearson correlation coefficient, linear regression and independent sample t-test were applied. Results: There was no significant correlation (95% CI [-0.013- 0.233]; p=0.07) between the frequency of ED and OPD visits. However, a significant correlation was found between ED visits and missed OPD appointments. Thus, linear regression was applied and indicated that one missed OPD appointment is associated with 1.92 ED visits, (95% CI: 0.19-0.42; p<0.001). Also, a higher rate of ED visits was observed when compared with other studies, with a high ED reliance of 43%. Conclusion: This study found that regular OPD visits could improve SCD management, as a directly proportional relationship between the frequency of ED visits and missed OPD appointments were found, along with high ED reliance.
Collapse
Affiliation(s)
- Abeer F Ismail
- Department of Pediatrics, Taibah University, Al Madinah Al Munawarah, Kingdom of Saudi Arabia. E-mail.
| | | | | | | | | |
Collapse
|
37
|
Mahabee-Gittens EM, Ammerman RT, Khoury JC, Tabangin ME, Ding L, Merianos AL, Stone L, Gordon JS. A Parental Smoking Cessation Intervention in the Pediatric Emergency Setting: A Randomized Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218151. [PMID: 33158230 PMCID: PMC7663571 DOI: 10.3390/ijerph17218151] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 01/05/2023]
Abstract
We examined the efficacy of a pediatric emergency visit-based screening, brief intervention, and referral to treatment (SBIRT) condition compared to a control condition (Healthy Habits Control, HHC) to help parental smokers quit smoking. We enrolled 750 parental smokers who presented to the pediatric emergency setting with their child into a two-group randomized controlled clinical trial. SBIRT participants received brief cessation coaching, quitting resources, and up to 12-weeks of nicotine replacement therapy (NRT). HHC participants received healthy lifestyle coaching and resources. The primary outcome was point-prevalence tobacco abstinence at six weeks (T1) and six months (T2). The mean (SD) age of parents was 31.8 (7.7) years, and 86.8% were female, 52.7% were Black, and 64.6% had an income of ≤$15,000. Overall abstinence rates were not statistically significant with 4.2% in both groups at T1 and 12.9% and 8.3% in the SBIRT and HHC groups, respectively, at T2. There were statistically significant differences in SBIRT versus HHC participants on the median (IQR) reduction of daily cigarettes smoked at T1 from baseline (−2 [−5, 0] versus 0 [−4, 0], p = 0.0008),at T2 from baseline (−4 [−9, −1] vs. −2 [−5, 0], p = 0.0006), and on the mean (SD) number of quit attempts at T2 from baseline (1.25 (6.5) vs. 0.02 (4.71), p = 0.02). Self-reported quitting rates were higher in SBIRT parents who received NRT (83.3% vs. 50.9%, p = 0.04). The novel use of the pediatric emergency visit to conduct cessation interventions helped parents quit smoking. The near equivalent abstinence rates in both the SBIRT and HHC groups may be due to underlying parental concern about their child’s health. Cessation interventions in this setting may result in adult and pediatric public health benefits.
Collapse
Affiliation(s)
- E. Melinda Mahabee-Gittens
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229–3026, USA;
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA; (R.T.A.); (J.C.K.); (M.E.T.); (L.D.)
- Correspondence: ; Tel.: +1-513-636-7966
| | - Robert T. Ammerman
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA; (R.T.A.); (J.C.K.); (M.E.T.); (L.D.)
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229–3026, USA
| | - Jane C. Khoury
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA; (R.T.A.); (J.C.K.); (M.E.T.); (L.D.)
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229–3026, USA
| | - Meredith E. Tabangin
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA; (R.T.A.); (J.C.K.); (M.E.T.); (L.D.)
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229–3026, USA
| | - Lili Ding
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA; (R.T.A.); (J.C.K.); (M.E.T.); (L.D.)
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229–3026, USA
| | - Ashley L. Merianos
- School of Human Services, University of Cincinnati, Cincinnati, OH 45221, USA;
| | - Lara Stone
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229–3026, USA;
| | - Judith S. Gordon
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
| |
Collapse
|
38
|
Zachariasse JM, Borensztajn DM, Nieboer D, Alves CF, Greber-Platzer S, Keyzer-Dekker CMG, Maconochie IK, Steyerberg EW, Smit FJ, Moll HA. Sex-specific differences in children attending the emergency department: prospective observational study. BMJ Open 2020; 10:e035918. [PMID: 32948551 PMCID: PMC7500294 DOI: 10.1136/bmjopen-2019-035918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the role of sex in the presentation and management of children attending the emergency department (ED). DESIGN The TrIAGE project (TRiage Improvements Across General Emergency departments), a prospective observational study based on curated electronic health record data. SETTING Five diverse European hospitals in four countries (Austria, The Netherlands, Portugal, UK). PARTICIPANTS All consecutive paediatric ED visits of children under the age of 16 during the study period (8-36 months between 2012 and 2015). MAIN OUTCOME MEASURES The association between sex (male of female) and diagnostic tests and disease management in general paediatric ED visits and in subgroups presenting with trauma or musculoskeletal, gastrointestinal and respiratory problems and fever. Results from the different hospitals were pooled in a random effects meta-analysis. RESULTS 116 172 ED visits were included of which 63 042 (54%) by boys and 53 715 (46%) by girls. Boys accounted for the majority of ED visits in childhood, and girls in adolescence. After adjusting for age, triage urgency and clinical presentation, girls had more laboratory tests compared with boys (pooled OR 1.10, 95% CI 1.05 to 1.15). Additionally, girls had more laboratory tests in ED visits for respiratory problems (pooled OR 1.15, 95% CI 1.04 to 1.26) and more imaging in visits for trauma or musculoskeletal problems (pooled OR 1.10, 95% CI 1.01 to 1.20) and respiratory conditions (pooled OR 1.14, 95% CI 1.05 to 1.24). Girls with respiratory problems were less often treated with inhalation medication (pooled OR 0.76, 95% CI 0.70 to 0.83). There was no difference in hospital admission between the sexes (pooled OR 0.99, 95% CI 0.95 to 1.04). CONCLUSION In childhood, boys represent the majority of ED visits and they receive more inhalation medication. Unexpectedly, girls receive more diagnostic tests compared with boys. Further research is needed to investigate whether this is due to pathophysiological differences and differences in disease course, whether girls present signs and symptoms differently, or whether sociocultural factors are responsible.
Collapse
Affiliation(s)
- Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC- Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dorine M Borensztajn
- Department of General Paediatrics, Erasmus MC- Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Claudio F Alves
- Department of Paediatrics, Emergency Unit, Hospital Professor Doutor Fernando da Fonseca, Amadora, Portugal
| | | | | | - Ian K Maconochie
- Department of Pediatric Emergency Medicine, Imperial College NHS Healthcare Trust, London, UK
| | - Ewout W Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank J Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC- Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
39
|
Patterns of Primary, Specialty, Urgent Care, and Emergency Department Care in Children With Inflammatory Bowel Diseases. J Pediatr Gastroenterol Nutr 2020; 71:e28-e34. [PMID: 32142000 PMCID: PMC8083894 DOI: 10.1097/mpg.0000000000002703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Pediatric patients with inflammatory bowel diseases (IBD) require treatment, monitoring, and health maintenance services. We described patterns of primary, specialty, emergency department (ED) and urgent care delivery, and explored patient- and system-related variables that impact ED/urgent care utilization. METHODS We conducted a cross sectional survey of parents of children with IBD at a large tertiary children's hospital. RESULTS One hundred sixty-one parents completed the survey (75% response). Mean patient age 13.9 years (51% boys); 80% Crohn disease, 16% ulcerative colitis, 4% IBD-unspecified. Mean disease duration 4 years (standard deviation [SD] 2.7). Thirty percent had at least 1 other chronic disease, 31% had a history of IBD-related surgery. Parents were predominantly Caucasian (94%), well-educated (61% bachelor's degree/higher), part of a 2-parent household (79%) living in a suburban setting (57%). Seventy-seven percent of patients had private insurance. In the past year, most children had 1 to 2 IBD-related office visits (54%) with their gastroenterology (GI) doctor and no IBD-related hospitalizations (79%). Eighty-eight percent (N = 141) had a primary care provider (PCP), and most (70%) saw their PCP 1 to 2 times. Even so, 86% (N = 139) received medical care from places other than their PCP or GI doctor; 27% in the ED and 45% at urgent care. Children of parents with less than a bachelor's degree, families that lived further from their GI doctor, and children who saw their PCP more often were more likely to utilize ED/urgent care. CONCLUSIONS ED/urgent care utilization in pediatric patients with IBD was greater than expected, potentially contributing to fragmented, costly care and worse outcomes.
Collapse
|
40
|
Percy Z, Brokamp C, McAllister JM, Ryan P, Wexelblatt SL, Hall ES. Subclinical and Overt Newborn Opioid Exposure: Prevalence and First-Year Healthcare Utilization. J Pediatr 2020; 222:52-58.e1. [PMID: 32423682 PMCID: PMC7412356 DOI: 10.1016/j.jpeds.2020.03.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/09/2020] [Accepted: 03/20/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To categorize newborn infants in Hamilton County, Ohio by late pregnancy fetal opioid exposure status and to assess their first-year healthcare utilization. STUDY DESIGN We used a population-based cohort of 41 136 live births from 2014-2017 and analyzed healthcare encounters in the first year of life from electronic health records. We prospectively assessed for the presence of opioids in maternal urine collected at delivery and for a diagnosis of newborn neonatal abstinence syndrome (NAS). At birth, infants were classified as unexposed to opioids, exposed to opioids and diagnosed with NAS, or subclinically exposed to opioids (exposure that did not result in NAS). RESULTS The prevalence of newborn opioid exposure was 37 per 1000 births. The duration of the hospital birth encounter was significantly longer for infants with subclinical exposure compared with unexposed infants (10% increase; 95% CI, 7%-13%). However, duration for infants with subclinical exposure was shorter compared to those with NAS. Neither subclinical exposure nor NAS was associated with total emergency department visits. Subclinical exposure was associated with increased odds of having at least 1 hospitalization in the first year. However, the total length of stay for hospitalizations was 82% that of the unexposed group (95% CI, 75%-89%). Infants with NAS had a 213% longer total length of stay compared with the unexposed group (95% CI, 191%-237%). CONCLUSIONS Subclinical and overt opioid exposure among newborn infants was associated with increased first-year healthcare utilization. From 2014 to 2017, this cost the Hamilton County healthcare system an estimated $1 109 452 for longer birth encounters alone.
Collapse
Affiliation(s)
- Zana Percy
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, Ohio,Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Cole Brokamp
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer M. McAllister
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick Ryan
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Scott L. Wexelblatt
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Eric S. Hall
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
41
|
Russell EA, Tsai C, Linton JM. Children in Immigrant Families: Advocacy Within and Beyond the Pediatric Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020; 21:100779. [PMID: 32922213 PMCID: PMC7480259 DOI: 10.1016/j.cpem.2020.100779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the United States, 1 in 4 children lives in an immigrant family. State and national policies have historically precluded equitable access to health care among children in immigrant families. More recently, increasingly restrictive policies, political rhetoric, and xenophobic stances have made immigrant families less able to access health care and less comfortable in attempting to do so, thus increasing the likelihood that patients will present to the emergency department. Once in the emergency department, language, cultural, and health literacy barriers make providing high-quality care potentially challenging for some families. Emergency care professionals can therefore glean critical insight regarding inequities from clinical work to inform advocacy and policy changes at institutional, community, regional, and national levels.
Collapse
Affiliation(s)
- Eric A Russell
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Carmelle Tsai
- Department of Pediatrics, Division of Emergency Medicine, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie M Linton
- Department of Pediatrics and Assistant Dean for Admissions, University of South Carolina School of Medicine Greenville and Prisma Health Children's Hospital, Greenville, SC
| |
Collapse
|
42
|
Macy ML, Kandasamy D, Resnicow K, Cunningham RM. Pilot Trial of an Emergency Department-based Intervention to Promote Child Passenger Safety Best Practices. Acad Emerg Med 2019; 26:770-783. [PMID: 30637887 PMCID: PMC6626697 DOI: 10.1111/acem.13687] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite demonstrated effectiveness of child restraint systems (CRSs), use remains suboptimal. In this randomized pilot trial, we sought to determine the feasibility, acceptability, and potential efficacy of "Tiny Cargo, Big Deal" an ED-based intervention to promote guideline-concordant size-appropriate CRS use. METHODS Parents of children < 11 years old were recruited in two EDs and randomized in a 2 × 2 factorial design to four conditions: 1) generic information sheet, 2) tailored brochure mailed after the ED visit, 3) a single motivational interviewing-based counseling session in the ED, and 4) full intervention (counseling session plus tailored brochure). We assessed feasibility (recruitment, completion, follow-up rates) and acceptability (parent attitudes, uptake of information) in the ED, at 1 month and at 6 months. We obtained preliminary estimates of effect sizes of the intervention components on appropriate CRS use at 6-month follow-up. RESULTS Of the 514 parents assessed for eligibility, 456 met inclusion criteria and 347 consented to participate. Enrolled parents were mostly mothers (88.1%); 48.7% were 18 to 29 years old; 52.5% were non-Hispanic, white; and 65.2% reported size-appropriate CRS use. Completion rates were 97.7% for baseline survey, 81.6% for counseling, 51.9% for 1-month follow-up, and 59.3% for 6-month follow-up. In the ED, 70.5% rated thinking about child passenger safety in the ED as very helpful. At 1 month, 70.0% expressed positive attitudes toward the study. Of 132 parents who reported receiving study mailings, 78.9% reviewed the information. Parents randomized to the full intervention demonstrated an increase (+6.12 percentage points) and other groups a decrease (-1.69 to -9.3 percentage points) in the proportion of children reported to use a size-appropriate CRS at 6-month follow-up. CONCLUSIONS Suboptimal CRS use can be identified and intervened upon during a child's ED visit. A combined approach with ED-based counseling and mailed tailored brochures shows promise to improve size-appropriate CRS use.
Collapse
Affiliation(s)
- Michelle L. Macy
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; The Child Health Evaluation and Research (CHEAR) Center, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan; The University of Michigan Injury Prevention Center, Ann Arbor, Michigan; Current affiliation: Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL;
| | - Deepika Kandasamy
- The Child Health Evaluation and Research (CHEAR) Center, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan; Current affiliation: Department of Emergency Medicine, University of Colorado-Denver, Aurora, Colorado;
| | - Ken Resnicow
- School of Public Health, University of Michigan, Ann Arbor, Michigan;
| | - Rebecca M. Cunningham
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; The University of Michigan Injury Prevention Center, Ann Arbor, Michigan; School of Public Health, University of Michigan, Ann Arbor, Michigan;
| |
Collapse
|
43
|
Hills-Dunlap JL, Melvin P, Graham DA, Kashtan MA, Anandalwar SP, Rangel SJ. Association of Sociodemographic Factors With Adherence to Age-Specific Guidelines for Asymptomatic Umbilical Hernia Repair in Children. JAMA Pediatr 2019; 173:640-647. [PMID: 31058918 PMCID: PMC6503577 DOI: 10.1001/jamapediatrics.2019.1061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Current guidelines recommend delaying repair of asymptomatic umbilical hernia in children until after age 4 to 5 years to allow for spontaneous closure. OBJECTIVE To examine the association of sociodemographic factors with adherence to age-specific guidelines for asymptomatic umbilical hernia repair in children. DESIGN, SETTING, AND PARTICIPANTS In this multicenter retrospective cohort study, children 17 years and younger who underwent umbilical hernia repair from January 2013 to June 2018 at 47 freestanding children's hospitals participating in the Pediatric Health Information System database were eligible for study inclusion. Children who underwent multiple procedures, repair of recurrent hernias, or had missing sociodemographic data were excluded. EXPOSURES Early umbilical hernia repair was defined as repair at 3 years or younger. Emergent or urgent presentation was defined as repair performed during the same encounter or within 2 weeks of an emergency department visit, respectively. Patients were categorized by sex, race/ethnicity, insurance type, income quintile, and presence of complex chronic conditions. MAIN OUTCOMES AND MEASURES Multivariable mixed-effects logistic regression was used to evaluate the association of sociodemographic factors with the odds of early repair after adjusting for emergent or urgent presentation and hospital-level effects. RESULTS Of the 25 877 included children, 13 817 (53.4%) were female, 14 143 (54.7%) had public insurance, and the median (interquartile range) age was 5.0 (3.0-6.0) years. Following adjustment, increased odds of early repair was associated with public insurance (public vs commercial insurance: odds ratio [OR], 1.46; 95% CI, 1.36-1.56; P < .001), lower income (lowest vs highest income quintile: OR, 1.48; 95% CI, 1.33-1.65; P < .001), and female sex (female vs male sex: OR, 1.20; 95% CI, 1.13-1.27; P < .001). Children with public insurance in the lowest income quintile had 2.2-fold increased odds of early repair compared with children with commercial insurance in the highest income quintile (OR, 2.15; 95% CI, 1.93-2.40; P < .001). Sociodemographic factors were not associated with increased odds of early repair in the subgroup of children who underwent early repair following emergent or urgent presentation. CONCLUSIONS AND RELEVANCE Public insurance, lower income, and female sex are independently associated with repair of asymptomatic umbilical hernias in children earlier than recommended by current guidelines. These children may be at greater risk of undergoing repair of umbilical hernias that may spontaneously close with further observation.
Collapse
Affiliation(s)
- Jonathan L. Hills-Dunlap
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts,Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, Boston, Massachusetts
| | - Dionne A. Graham
- Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark A. Kashtan
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seema P. Anandalwar
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
44
|
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.
Collapse
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
| |
Collapse
|
45
|
Bajaj L. The Impact of the Evolving Health Care System on Pediatric Emergency Care. Pediatr Clin North Am 2018; 65:1247-1256. [PMID: 30446060 DOI: 10.1016/j.pcl.2018.07.007] [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] [Indexed: 10/27/2022]
Abstract
This article discusses the implications of health care reform on the pediatric emergency department (ED). The author briefly discusses the health care costs and outcomes in the United States in comparison to other developed nations. The article discusses the impact of the Affordable Care Act and insurance expansion on the pediatric ED. Then the article addresses the impacts of the growing patient financial responsibility on ED use. There will be a discussion of the development of pediatric accountable care organizations and how payment mechanisms are evolving, and the challenges the pediatric ED may face in these new payment strategies.
Collapse
Affiliation(s)
- Lalit Bajaj
- Clinical Effectiveness, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue B400, Aurora, CO 80045, USA.
| |
Collapse
|