Ambulatory follow-up among publicly insured children discharged from the emergency department

Application of the Diagnosis Grouping System to Pediatric Emergency Department Encounters

OBJECTIVE

Diagnosis grouping systems are essential for health services and epidemiological and health outcomes research. The Diagnosis Grouping System (DGS) was developed to classify International Classification of Diseases, 10th Revision diagnosis codes for pediatric emergency department (ED) encounters. We applied and compared the DGS to large samples of US ED encounters for children using 3 large health system databases.

METHODS

We conducted a retrospective cross-sectional study of children (younger than age 18 years) between 2016 and 2021 using 3 ED datasets: the National Hospital Ambulatory Medical Care Survey (NHAMCS; a complex survey of US ED encounters), COMPdata (a dataset of encounters for Illinois), and the Pediatric Health Information Systems (PHIS; an administrative database of US children's hospitals). We categorized principal diagnoses using the DGS and compared their distribution.

RESULTS

We included 181 607 978 survey-weighted encounters from NHAMCS, 5 352 016 encounters from COMPdata, and 20 859 019 encounters from PHIS. A higher proportion of encounters in the PHIS sample were admitted or transferred (12.7%) compared with those in the NHAMCS (6.1%) or COMPdata (4.2%) samples. Trauma was the most common major group identified among all datasets (22.0% in NHAMCS, 22.2% in COMPdata, and 17.0% in PHIS). Some conditions, such as sickle cell anemia, diabetes mellitus, appendicitis, seizures, and asthma, presented more frequently among children presenting to the PHIS hospitals.

CONCLUSIONS

We identified comparable diagnostic distributions across different datasets, with differences that are likely attributable to specific characteristics of the data source. Our findings provide a baseline for pediatric diagnoses to facilitate future research on pediatric ED utilization.

Outpatient follow-up and future care-seeking for pediatric ambulatory care-sensitive conditions

OBJECTIVES

Outpatient follow-up visits are often recommended for children with ambulatory care-sensitive conditions (ACSCs) who are discharged from emergency departments or urgent care centers (acute care settings). We sought to assess whether attending a follow-up visit within 7 days is associated with seeking initial office-based care rather than acute care during a subsequent ACSC illness. Understanding this association is crucial to guide recommendations for routine short-term follow-up visits in children who seek acute care for these common conditions.

METHODS

This was a cohort study of Medicaid-insured children younger than 18 years diagnosed with ACSCs and discharged from acute care settings in a multistate claims database in 2017-2019. We used generalized estimating equations to assess the association between a follow-up visit within 7 days and the site of initial care (office vs. acute care) during a subsequent ACSC illness. Models were adjusted for demographics, clinical characteristics, and prior patterns of healthcare utilization.

RESULTS

Among 866,392 acute care visits for ACSCs, 250,578 (28.9%) had an outpatient follow-up visit within 7 days. Follow-up was independently associated with increased odds of initial office-based care rather than initial acute care during the subsequent ACSC illness (adjusted OR [aOR], 1.41, 95% CI, 1.39-1.42).

CONCLUSIONS

Outpatient follow-up after acute care visits for ACSCs was associated with increased odds of initial office-based care during the next illness episode. This association may support recommendations for follow-up visits for certain children to promote subsequent utilization of office-based settings during acute illnesses.

Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers

OBJECTIVE

National efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, emphasizing the need to maintain pediatric readiness in these settings. We aimed to characterize emergency medical services (EMS) utilization from outpatient offices and urgent care centers to better understand pediatric readiness needs.

METHODS

We performed a retrospective cross-sectional analysis of EMS encounters using the National Emergency Medical Services Information System, a nationally representative EMS registry (2019-2022). We included four years of EMS encounters of children (<18 years old) that originated from an outpatient office or urgent care center. We described characteristics, including patient demographics, prehospital clinician impression, therapies, and procedures performed.

RESULTS

Of 179,854,336 EMS encounters during the study period, 164,387 pediatric encounters originated at an outpatient setting. Most EMS encounters originated from outpatient offices. Evening and weekend EMS encounters more frequently originated from urgent care centers. The most common impressions were respiratory distress (n = 60,716), systemic illness (n = 23,583), and psychiatric/behavioral health (n = 13,273). Ninety-four percent of EMS encounters resulted in transportation to a hospital.

CONCLUSIONS

EMS encounters from outpatient settings most commonly originate from outpatient offices, relative to urgent care settings, where pediatric emergency readiness may be limited. It is important that outpatient settings and providers are ready for varied emergencies, including those occurring for a behavioral health concern, and that readiness guidelines are updated to address these needs.

Acute care utilization for ambulatory care-sensitive conditions among publicly insured children

BACKGROUND

Although characteristics of preventable hospitalizations for ambulatory care-sensitive conditions (ACSCs) have been described, less is known about patterns of emergency and other acute care utilization for ACSCs among children who are not hospitalized. We sought to describe patterns of utilization for ACSCs according to the initial site of care and to determine characteristics associated with seeking initial care in an acute care setting rather than in an office. A better understanding of the sequence of health care utilization for ACSCs may inform efforts to shift care for these common conditions to the medical home.

METHODS

We performed a retrospective analysis of pediatric encounters for ACSCs between 2017 and 2019 using data from the IBM Watson MarketScan Medicaid database. The database includes insurance claims for Medicaid-insured children in 10 anonymized states. We assessed the initial sites of care for ACSC encounters, which were defined as either acute care settings (emergency or urgent care) or office-based settings. We used generalized estimating equations clustered on patient to identify associations between encounter characteristics and the initial site of care.

RESULTS

Among 7,128,515 encounters for ACSCs, acute care settings were the initial site of care in 27.9%. Diagnoses with the greatest proportion of episodes presenting to acute care settings were urinary tract infection (52.0% of episodes) and pneumonia (44.6%). Encounters on the weekend (adjusted odds ratio [aOR] 6.30, 95% confidence interval [CI] 6.27-6.34 compared with weekday) and among children with capitated insurance (aOR 1.55, 95% CI 1.54-1.56 compared with fee for service) were associated with increased odds of seeking care first in an acute care setting.

CONCLUSIONS

Acute care settings are the initial sites of care for more than one in four encounters for ACSCs among publicly insured children. Expanded access to primary care on weekends may shift care for ACSCs to the medical home.