Lower rates of emergency department injury visits among Latino children in the USA: no association with health insurance

Epidemiology of readmissions in early infancy following nonelective cesarean delivery

OBJECTIVE

Determine incidence and risk factors for readmissions in early infancy.

STUDY DESIGN

Secondary analysis of data from the Cesarean Section Optimal Antibiotic Prophylaxis trial. All unplanned revisits (unplanned clinic, ER visits, and hospital readmissions) and hospital readmissions (initial discharge to 3-month follow-up) were analyzed.

RESULTS

295 (15.9%) of 1850 infants had revisits with risk factors being ethnicity (adjusted odds ratio (aOR): 0.6 for Hispanic), maternal postpartum antibiotics (1.89), azithromycin treatment (1.22), small for gestational age (1.68), apnea (3.82), and hospital stay after birth >90th percentile (0.49). 71 (3.8%) of 1850 infants were readmitted with risk factors being antenatal steroids (aOR 2.49), elective repeat C/section (0.72), postpartum maternal antibiotics (2.22), O₂ requirement after delivery room (2.82), and suspected/proven neonatal sepsis (0.55).

CONCLUSION(S)

Multiple risk factors were identified, suggesting potential impact on the neonatal microbiome (maternal postpartum antibiotics) or issues related to access/cost of care (Hispanic ethnicity associated with fewer revisits).

Patient- and Community-Level Sociodemographic Characteristics Associated with Emergency Department Visits for Childhood Injury

OBJECTIVE

To examine pediatric emergency department (ED) visits over 5 years, trends in injury severity, and associations between injury-related ED visit outcome and patient and community-level sociodemographic characteristics.

STUDY DESIGN

Retrospective analysis of administrative data provided to the Pediatric Emergency Care Applied Research Network Core Data Project, 2004-2008. Home addresses were geocoded to determine census block group and associated sociodemographic characteristics. Maximum Abbreviated Injury Scale severity and Severity Classification System scores were calculated. Generalized estimating equations were used to test for associations between sociodemographic characteristics and admission or transfer among injury-related ED visits.

RESULTS

Overall ED visits and injury-related visits increased from 2004 to 2008 at study sites. Of 2,833676 successfully geocoded visits, 700,821 (24.7%) were injury-related. The proportion of higher severity injury-related visits remained consistent. Nearly 10% of injury-related visits resulted in admission or transfer each year. After adjusting for age, sex, payer, and injury severity, odds of admission or transfer were lower among minority children and children from areas with moderate and high prevalence of poverty.

CONCLUSIONS

Pediatric injury-related ED visits to included sites increased over the study period while injury severity, anticipated resource utilization, and visit outcomes remained stable, with low rates of admission or transfer. Sociodemographic differences in injury-related visits and ED disposition were apparent. ED-based injury surveillance is essential to understand disparities, inform targets for prevention programs, and reduce the overall burden of childhood injuries.

US emergency department use by children, 2001-2010

OBJECTIVE

Children commonly use emergency departments (EDs) for a variety of health care needs. We describe recent trends in US ED use by children.

METHODS

This is a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits, and US Census data between 2001 and 2010. We examined demographic trends, visit characteristics, insurance status, disposition, hospital variables, diagnoses, reason for visit, and resource use among patients younger than 19 years. Linear regression was used to evaluate significance of trends.

RESULTS

Approximately one quarter of all ED visits was made by patients younger than 19 years. Emergency department visits by children increased 14.4% between 2001 and 2010 (P = 0.04); the rate of visits increased from 36.4 to 40.6 per 100 population. Trauma is the most common reason for pediatric ED visits. Black children had the highest rate of ED use (61.9 per 100 in 2010). Visit rates by Hispanic children were relatively low but increased by 82.7% since 2001 (P = 0.00). The proportion of ED visits by Medicaid beneficiaries rose from 32.0% to 51.9% (P = 0.00). The volume and frequency of diagnostic testing, administration of intravenous fluids, medication administration, and discharge prescriptions increased. Visits with computed tomography or magnetic resonance imaging almost doubled from 3.1% of the visits in 2001 to 6.6% of the visits in 2010 (P = 0.00).

CONCLUSIONS

The use of ED by children is growing faster than population growth, and the intensity of ED care has risen sharply. Hispanic children and Medicaid beneficiaries represent the fastest growing populations of children using the ED.

Factors associated with nonurgent use of pediatric emergency care among Latino families

OBJECTIVE

This study investigates Latino parents' decision to seek pediatric emergency care for nonurgent health conditions.

METHODS

Three focus groups were conducted with Spanish-speaking parents. Eligible families had a pediatric primary care provider, and their child received emergency treatment for a nonurgent health condition in the previous year. Transcripts were transcribed, translated, and thematically coded.

RESULTS

Parents shared a heightened concern about symptoms such as fever or diminished energy. Many related experiences where delay resulted in serious illness or death. Other factors included low utilization of telephone triage and long clinic wait times. Nearly every family had managed the child's illness at home prior to seeking care, employing medical and natural remedies.

CONCLUSIONS

The study findings suggest that strengthening the connection with a child's medical home, eliminating barriers to receiving primary care in urgent situations and educating parents about management of common illnesses may improve care for Latino children.

Association of externalizing behavior disorder symptoms and injury among fifth graders

OBJECTIVE

Injury is the leading cause of death among American youth, killing more 11-year-olds than all other causes combined. Children with symptoms of externalizing behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) may have increased risk. Our aims were to determine: (1) whether increasing symptoms of ADHD and CD associate positively with injuries among a community sample of fifth graders; and (2) whether symptoms of ADHD and CD have a multiplicative rather than additive association with injuries among the sample.

METHODS

Data were collected from 4745 fifth graders and their primary caregivers participating in Healthy Passages, a multisite, community-based study of pediatric health risk behaviors and health outcomes. The primary outcome was injury frequency. Primary independent variables were ADHD and CD symptoms. Additional covariates included gender, race/ethnicity, and household income. Ordinal logistic regression examined correlates of injury frequency. The interaction between ADHD and CD symptoms also was examined.

RESULTS

In bivariate analyses, the odds of injury increased as ADHD symptoms (odds ratio [OR] 1.29; 95% confidence interval [95% CI] 1.18-1.41) and CD symptoms (OR 1.18; 95% CI 1.07-1.31) increased. However, in multivariate analysis, only ADHD symptoms were significantly associated with injury (OR 1.22; 95% CI 1.10-1.35). There was no statistically significant interaction between ADHD and CD symptoms.

CONCLUSIONS

ADHD symptoms are associated with increased odds of injury in fifth graders. Findings have implications for potential injury prevention strategies for mental health practitioners (for example, cognitive training with at-risk youth), pediatricians (ADHD screening), and parents (improved supervision).

An epidemiologic comparison of injuries presenting to a pediatric emergency department and local urgent care facilities

PROBLEM

The objective of this study was to compare the epidemiology of injuries presenting to emergency department (ED) and urgent care (UC) facilities of a single, NEISS-affiliated hospital.

METHOD

Patient medical records (n=36,811) were used to compare injury incidence, injury characteristics, and demographic characteristics between the ED, on-site UC, and off-site UC during 2006.

RESULTS

ED presentations were more likely to be open wounds and motor vehicle-related compared to on-site UC presentations. ED presentations were more likely to be system wide/late effects, be made by an African American, or be paid through Medicaid compared to off-site UC presentations. On-site UC presentations were more likely to be made by an African American or be paid through Medicaid compared to off-site UC presentations.

DISCUSSION

ED and UC injury characteristics and patient demographics differ. With no nationally-representative UC injury surveillance, current research likely underestimates injury incidence and presents skewed profiles.

IMPACT ON INDUSTRY

This article adds insight into the generalizability of ED-based injury surveillance to UC injuries.

Annual report on health care for children and youth in the United States: focus on injury-related emergency department utilization and expenditures

OBJECTIVE

To examine state differences in children's utilization of injury-related emergency department (ED) care across 14 states, benchmarking aggregate state estimates against national expenditure estimates for outpatient injury-related ED care.

METHODS

A retrospective analysis was performed using the 2003 State Emergency Department Databases and State Inpatient Databases from the Healthcare Cost and Utilization Project and data from the Medical Expenditure Panel Survey. Pediatric ED visits with any injury International Classification of Diseases Ninth Version Clinical Modification (ICD-9-CM) diagnosis code were selected. The Barell Injury Diagnosis Matrix, ICDMAP-90 software, and the Trauma Information Exchange Program data were used to classify injuries, produce injury severity scores, and examine utilization in trauma centers. Aggregate and state-specific descriptive analyses compared differences in patient and injury characteristics and admission status by age, severity of injury, and expected payer.

RESULTS

Over 1.5 million or nearly one-third of ED visits were for pediatric injuries in the 14 states studied. Nationally, 5.4% of children had an injury-related ED visit, and approximately $2.3 billion was spent on outpatient injury-related ED visits in 2003. The pattern of injury-related ED visit care varied considerably by state. For example, injury-related ED visit rates ranged from 63.3 to 164.4 per 1000 children. Infants, adolescents, children from very low income communities, and children from nonmetropolitan and nonmicropolitan areas were more likely to have an injury-related ED visit than their peers. Although patient characteristics were fairly consistent across states, admission rates and expected source of payment for injury-related ED visits varied considerably by state. Hospital admission rates ranged from 1.5% to 4.4% of injury-related ED visits and expected payer estimates ranged from 37.1% to 71.0% of visits billed to private insurance, 17.9% to 47.0% billed to Medicaid, and 2.1% to 10.4% billed as uninsured.

CONCLUSIONS

This study suggests that injuries account for a significant portion of pediatric ED visits. There is substantial variation in ED use and hospital admissions for injured children across states and payers. This variation suggests that there are several opportunities for improvement in emergency care for children. To better understand the underlying reason for the variation, multivariate and hypothesis-driven research should focus on the nature and outcomes of injury-related ED care in the context of small area practice patterns and state programs, policies, and care system characteristics.

Are the uninsured responsible for the increase in emergency department visits in the United States?

STUDY OBJECTIVE

The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits.

METHODS

Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance.

RESULTS

The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74).

CONCLUSION

The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office.