Determinants of nonurgent use of the emergency department for pediatric patients in 12 hospitals in Belgium

Avoidable visits to the paediatric emergency department: associated factors and lessons learned from the pandemic

PURPOSE

The main goal of this study is to identify the associated factors with avoidable admissions in ED, comparing pre-COVID and COVID periods.

METHODS

This was retrospective study that took place in a Paediatric Emergency Department of a metropolitan, university-affiliated hospital in Portugal. All visits to paediatric emergency department between 2014 and 2020 were considered.

RESULTS

There was a decrease of 7.2% points in avoidable visits between pre-COVID and COVID periods. Considering both periods, this study identifies older ages, being admitted to the paediatric emergency department between 4 and 7 a.m., referral and having visited the emergency department previously within 72 h as major factors associated with a reduced likelihood for avoidable visits. On the other hand, it identifies an increased likelihood of avoidable visits in the 3 to 5 years old age group, visits that occurred during the Summer and visits that occurred between 8 and 11 p.m. When considering what changed between pre-COVID and COVID periods, while having visited the paediatric emergency department 72 h prior made it less likely for the patient to be an avoidable visit during the pandemic period, this tendency has inverted, making it more likely for return visits to be avoidable.

CONCLUSIONS

The relatively low decrease in avoidable visits' ratios between pre-COVID and COVID periods, associated with the similar distribution of attendance during the day and lower odds ratio of avoidable visits during periods when primary care is available, suggests that avoidable visits are a chronical problem of the National Health system's structure and its usage, not having a single factor nor a combination of factors as a driving force. Nevertheless, this study identified several factors associated with avoidable visits to the emergency department. Therefore, it can aid policy makers to create targeted interventions to mitigate this problem.

Distances to emergency departments and non-urgent utilization of medical services: a systematic review

BACKGROUND

The use of Emergency Departments (EDs) for non-urgent medical conditions is a global public health concern.

OBJECTIVES

A systematic review, guided by a registered protocol (PROSPERO: CRD42023398674), was conducted to interpret the association between distance as a measure of healthcare access and the utilization of EDs for non-urgent care in high- and middle-income countries.

METHODS

The search was conducted on 22 August 2023 across five databases using controlled vocabulary and natural language keywords. Eligibility criteria included studies that examined non-urgent care, and featured concepts of emergency departments, non-urgent health services and distance, reported in English. Articles and abstracts where patients were transported by ambulance/paramedic services, referred/transferred from another hospital to an ED, or those that measured distance to an ED from another health facility were excluded. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework informed the quality of evidence.

RESULTS

Fifteen articles met the inclusion criteria. All studies demonstrated satisfactory quality with regard to study design, conduct, analysis and presentation of results. Eight (53.3%) of the studies (1 paediatric, 4 all ages/adult, 3 ecological) found a moderate level of evidence of an inverse association between distance and ED visit volume or utilization for non-urgent medical conditions, while the remaining studies reported very low or low evidence.

CONCLUSIONS

Half of the studies reported non-urgent ED use to be associated with shortest distance traveled or transportation time. This finding bears implications for healthcare policies aiming to reduce ED use for non-urgent care.

Children accessing accident and emergency department for non-urgent consultations: A cross-sectional study about parents' use of primary care services

INTRODUCTION

Parents often take their children to the Paediatric Accident and Emergency Department (A&E) for non-urgent consultations rather than using community-based primary care services. This study describes the use of primary care services in parents taking their children to the A&E for non-urgent consultations.

METHODS

A cross-sectional study was conducted from July 2018 to June 2019, in a second-level Italian paediatric A&E of a tertiary-level children's academic research and hub hospital. Parents of children aged between 3 months and 6 years assigned with a white code at the triage were asked to complete a paper-and-pencil 40-item questionnaire after accessing the A&E for a non-urgent consultation.

RESULTS

The questionnaire was completed by the parents of 237 children (males 58 %; median age = 2.3 years). Overall, 48.1 % (n = 114) of the parents reported consulting 'often/always' the primary care paediatrician, mainly when their child was sick and for check-ups (n = 182, 76.8 %). However, only 7.2 % (n = 17) of the parents 'often/always' used any other health service in the community. Most of them (n = 191, 82 %) did not even know where the community health centre was located.

CONCLUSION

Parents accessing the A&E for non-urgent consultations should be better informed/educated on how to use community health services.

Assessment of Medical Test Overuse and Its Impact on Pediatric Emergency Department Outcomes in Upper Respiratory Tract Infections in a University Hospital in Lithuania

Medical overuse poses potential risks to patients and contributes to increasing healthcare costs, pediatric emergency departments (PED) in particular. Often, upper respiratory tract infection (URTI) cases are viral-induced and self-limiting, and they do not require specific investigations or treatment. We conducted a retrospective study from 1 December 2021 to 31 January 2022, thereby aiming to identify the common tests and factors influencing specific diagnostic and treatment decisions for URTI in PED. In total, 307 (74.9%) URTI cases underwent complete blood count (CBC) tests, 312 (76.1%) were subjected to C-reactive protein (CRP) tests, and 110 (26.8%) received urinalysis tests. Patients with a longer duration of fever and a physician's suspicion of bacterial infection were more likely to receive CBC, CRP, and/or urinalysis tests (p < 0.05). Moreover, 75.1% of the cases were classified as viral URTIs, 9.8% were bacterial URTIs, and 15.1% were unspecified. Notably, 86 (20.1%) children received antibiotics and antibiotic prescription correlated with age, tonsillitis diagnosis, CRP values higher than 30 mg/L, and a CBC of p < 0.05. Patients triaged in the second or third categories were three times more likely to be observed for 24 h compared to patients with URTI and the fourth triage category (p < 0.05). This study highlights the need for interventions to improve the appropriateness of emergency service utilization, thereby emphasizing the importance of judicious decision making in managing pediatric URTIs.

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada

OBJECTIVE

To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays.

PARTICIPANTS

Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients.

RESULTS

We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)).

CONCLUSIONS

The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

Effects of Closure of the Paediatric Department of a District Hospital on Regional Care: Analysis of Patient Flows

BACKGROUND

The consequences of economization and staff shortage in the German health care system strongly affect paediatric care structures, especially in rural regions. It is not known how closures of paediatric departments influence patient flows of surrounding hospitals. Here, we investigate the quantitative effects of closure of the paediatric department of a district hospital and the subsequent opening of an alternative inpatient service on the utilisation of inpatient and outpatient care services of the two neighboring hospitals and the emergency services of the region.

METHODOLOGY

In the observation period from 2015 to 2019, patient-related data from the three hospitals in the study region as well as data from the rescue service were evaluated.

RESULTS

In the year after the paediatric department of the district hospital was closed in 2016, the total number of inpatient cases in the region decreased by 33% (2015: n=1,787; 2016: n=1,193) and then decreased by an additional 11% (2019: n=1,005). The number of outpatient cases decreased by further 8% (2015: n=6,250; 2019: n=5,770). In the last observation year, emergency services were used much more frequently than in the year before the closure (2015: n=398; 2019: n=572). This means an increase of 44%.

CONCLUSION

After the closure of the paediatric department, the total number of inpatient cases in the region fell sharply. However, actual gaps in care apparently did not arise. Before closing, the consequences for the surrounding hospitals should be assessed more precisely. Real gaps in care must be counteracted, e. g. through alternative outpatient services.

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

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

Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation

OBJECTIVES

Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity.

METHODS

Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department.

RESULTS

Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity.

CONCLUSIONS

Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.

Age-varying effects of repeated emergency department presentations for children in Canada

Objectives

Repeated presentations to emergency departments (EDs) may indicate a lack of access to other health care resources. Age is an important predictor of frequent ED use; however, age-varying effects are not generally investigated. This study examines the age-specific effects of predictors on ED presentation frequency for children in Alberta and Ontario, Canada.

Methods

This retrospective study used population-based data during April 2010 to March 2017. Data were extracted from the National Ambulatory Care Reporting System for children aged <18 who were members of the top 10% of ED users in any one of the fiscal years 2011/2012 to 2015/2016 along with a comparison sample from the bottom 90%. A marginal regression model studied the age-varying associations on the frequency of ED presentations with province, sex, access to primary health care provider (for Ontario only), area of residence and lowest neighbourhood income quintile.

Results

There were 2,481,172 patients who made 9,229,156 ED presentations. The effects of sex, lowest income quintile, rural residence, access to primary health care provider and province on the frequency of presentations varied by age. Notably, boys go from having more frequent presentations than girls when aged ≤5 (i.e. adjusted intensity ratio [IR]=1.04 at age 5, 95% confidence interval [CI] = 1.03,1.06) to less frequent for ages 8–11 years and beyond 14 (i.e. IR = 0.80 at age 15, 95% CI = 0.78,0.81). Adolescents aged ≥15 without access to a primary care provider had more frequent presentations compared to those with a primary care provider.

Conclusions

When examining the frequency of ED presentations in children, age-varying effects of predictors should be considered. Our more nuanced examination of age provides insights into how health services might better target programmes for different ages to potentially reduce unnecessary ED use by providing other health care alternatives.

Nonurgent Visits to the Pediatric Emergency Department before and during the First Peak of the COVID-19 Pandemic

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.

Régulation médicale de la dyspnée de l’enfant : intérêt d’une régulation pédiatrique

Introduction :L’évaluation téléphonique du patient pédiatrique peut être difficile à la régulation médicale du Samu-Centre 15 (aide médicale urgente [AMU] ou permanence de soins [PDS]). La dyspnée est un motif d’appel fréquent dans cette population et présente des particularités importantes comparée à la population adulte. Nous avons voulu évaluer la pertinence de l’évaluation téléphonique de la dyspnée en pédiatrie selon la qualification du médecin régulateur (urgentiste, généraliste ou pédiatre).

Matériel et méthode :Il s’agit d’une étude observationnelle rétrospective monocentrique menée au Samu de Haute-Garonne entre le 1er décembre 2018 au 31 janvier 2019. Les critères d’inclusion étaient un appel pour tout patient avec un âge inférieur à dix ans pour dyspnée. Le critère de jugement principal était le surtriage.

Résultats : Nous avons analysé 717 appels pour dyspnée pédiatrique sur la période. La non-adéquation entre la décision médicale et le devenir du patient était retrouvée chez 174 patients (24 %) : 173 patients (99 %) étaient surtriés et un patient était sous-trié (< 1 %). En analyse multivariée, les facteurs protecteurs de surtriage étaient l’âge de six mois à trois ans (OR = 0,56 ; IC 95 % = [0,36–0,86]) comparé à un âge jeune (≤ 6 mois ; référence) et l’évaluation par un régulateur de PDS (OR = 0,38 ; IC 95 % = [0,23–0,62]) ou pédiatre (OR = 0,54 ; IC 95 % = [0,34–0,86]) comparé à un régulateur de l’AMU (référence). L’appel nocturne était un facteur de risque de surtriage (OR = 1,98 ; IC 95 % = [1,39–2,84]).

Conclusion : La régulation par un pédiatre ou un médecin de la PDS permet de réduire le surtriage dans un centre où les régulateurs AMU n’ont pas d’activité pédiatrique clinique.

Pediatric patients accessing Accident and Emergency Department (A&E) for non-urgent treatment: Why do parents take their children to the A&E?

INTRODUCTION

About 20-30% of children access the Pediatric Accident and Emergency Department (A&E) for non-urgent health care that should normally follow other health care paths. This study aimed to investigate why parents take their children to the A&E for non-urgent visits rather than using primary care services.

METHODS

A one-year cross-sectional study was conducted in a large pediatric A&E in Italy. A paper-and-pencil 40-item questionnaire was administered to parents of children aged between 3 months to 6 years who accessed the A&E for non-urgent visits between July 2018 and June 2019.

RESULTS

Parents of 238 children completed the questionnaire (mean age = 2.6 years; male 58%). The most common symptoms were fever (n = 105; 44.1%) and skin rash (n = 63; 26.5%); symptoms usually started more than 24 h earlier (n = 163; 69.4%). Reasons for accessing the A&E for non-urgent visits included the availability of rapid medical tests (n = 71; 29.8%), deterioration of the clinical conditions after the pediatrician's visit (n = 67; 28.2%), and the perceived need for urgent care (n = 65; 27.3%). Besides, 26.6% (n = 63) of parents reported not being able to contact their pediatrician before accessing A&E.

CONCLUSION

Parents may need further education to distinguish between urgent and non-urgent pediatric health conditions.

Policy of free GP care for children under 6 years: The impact on emergency department attendance

Universal health coverage (UHC) aims to improve child health. Ireland, the only country in the European Union without universal access to primary care, introduced general practitioner (GP) care at no charge for children aged under six in 2015. This paper aims to evaluate the impact of this policy on attendance at the emergency department (ED). A difference-in-difference (DiD) analysis was applied to visit records of 367,000 paediatric patients at five hospitals over a period of five years, with treatment and control differentiated by age. DiD was also used to assess if GP referrals and the severity of presentations altered as a consequence of this policy. While existing research estimates that this policy increased attendance by children aged under six at general practice by over 25%, this policy did not lead to a reduction in ED attendance. Hospital level effects on attendance varied from no impact to increased attendance by children aged under six of 28.9%. While increased GP referrals, particularly for injury and medical reasons, indicated more patients presented to their GP prior to ED attendance, walk-ins without referral did not decrease. Attendance increased at both regional hospitals, which also had the highest proportion of GP referred visits. While the marginal probability of a visit being GP referred increased at four of the five hospitals in this study, only in two of these can the entire effect be attributed to the introduction of this policy (effects 1.4 and 1.8 percentage points). Previous unmet need, capacity constraints in general practice, regional variability in the GP to population ratio, restricted hours of access to GPs, coupled with faster access to diagnostics in the ED setting, may explain variability in the effect and why the expected reduction in ED attendances did not occur.

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

BACKGROUND

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

OBJECTIVE

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

DATA SOURCES

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

STUDY ELIGIBILITY CRITERIA

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

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

Low acuity paediatric emergency visits under single-payer universal health insurance in Taiwan, 2000-2015: a population-based repeated cross-sectional design

OBJECTIVES

Emergency services utilisation is a critical policy concern. The paediatric population is the main user of emergency department (ED) services, and the main contributor to low acuity (LA) ED visits. We aimed to describe the trends of ED and LA ED visits under a comprehensive, universal health insurance programme in Taiwan, and to explore factors associating with potentially unnecessary ED utilisation.

DESIGN AND SETTING

We used a population-based, repeated cross-sectional design to analyse the full year of 2000, 2005, 2010 and 2015 National Health Insurance claims data individually for individuals aged 18 years and under.

PARTICIPANTS

We identified 5 538 197, 4 818 213, 4 401 677 and 3 841 174 children in 2000, 2005, 2010 and 2015, respectively.

PRIMARY AND SECONDARY OUTCOME MEASURES

We adopted a diagnosis grouping system and severity classification system to define LA paediatric ED (PED) visits. Generalised estimating equation was applied to identify factors associated with LA PED visits.

RESULTS

The annual LA PED visits per 100 paediatric population decreased from 10.32 in 2000 to 9.04 in 2015 (12.40%). Infectious ears, nose and throat, dental and mouth diseases persistently ranked as the top reasons for LA visits (55.31% in 2000 vs 33.94% in 2015). Physical trauma-related LA PED visits increased most rapidly between 2000 and 2015 (0.91-2.56 visits per 100 population). The dose-response patterns were observed between the likelihood of incurring LA PED visit and either child's age (OR 1.06-1.35 as age groups increase, p<0.0001) or family socioeconomic status (OR 1.02-1.21 as family income levels decrease, p<0.05).

CONCLUSION

Despite a comprehensive coverage of emergency care and low cost-sharing obligations under a single-payer universal health insurance programme in Taiwan, no significant increase in PED utilisation for LA conditions was observed between 2000 and 2015. Taiwan's experience may serve as an important reference for countries considering healthcare system reforms.

Use and Misuse of Emergency Room for Children: Features of Walk-In Consultations and Parental Motivations in a Hospital in Southern Italy

Objective: Inappropriate use of the emergency department (ED) represents a major worldwide issue both in pediatric and adult age. Herein, we aim to describe features of pediatric visits to the ED of Salerno University Hospital and to evaluate parental reasons behind the decision to walk in. Materials and Methods: We performed a retrospective observational study evaluating ED encounters for children from January 2014 to December 2019. The appropriateness of visits was measured with a national tool assessing every ED encounter, namely, "the Mattoni method," which consists of the combination of the triage code assigned, the diagnostic resources adopted, and the consultation outcomes. Moreover, 64 questionnaires were collected from a sample of parents in the waiting rooms in January 2020. Results: A total number of 42,507 visits were recorded during the study period (19,126 females; mean age ± SD: 4.3 ± 3.8 years), the majority of whom were inappropriate (75.8% over the considered period; 73.6% in 2014; 74.6% in 2015; 76.3% in 2016; 76.7% in 2017; 77.9% in 2018; 75.5% in 2019). Most of the inappropriate consultations arrived at the ED by their own vehicle (94.4%), following an independent decision of the parents (97.2%), especially in the evening and at night on Saturdays/Sundays/holidays (69.7%). A multivariate analysis revealed the following: patients of younger age (OR: 1.11, 95% C.I. 1.06-1.16; p < 0.0019), night visits (OR 1.39; 95% C.I.: 1.32-1.47; p < 0.001), patients living in the municipality of Salerno (OR 1.28; 95% C.I.: 1.22-1.34; p < 0.001), weekend day visits (OR 1.48; 95% C.I.: 1.41-1.56; p < 0.001), and independent parental decision without previous contact with primary care pediatrician (OR 3.01; 95% C.I.: 2.64-3.44; p < 0.001) were all significant independent predictors of inappropriate consultation. The most frequent trigger of ED encounters was fever (51.4%). Hospital admission made up 17.6% of all consultations. The questionnaire showed that most parents were aware of the lack of urgency (20.3%) or minor urgency (53.1%) of the visit. The reasons for walking in were the impossibility to receive a home consultation (70%), the difficulty of contacting their family pediatrician during weekends and holidays (54.4%), as well as the search for a quick, effective, diagnosis and therapy (48.4%). Conclusions: The study suggests a highly inappropriate use of ED for children in our region. This issue deserves considerable attention by health care system leaders in order to optimally integrate hospitals and primary care.

Characteristics of low-acuity paediatric emergency department consultations in two tertiary hospitals in Switzerland: a retrospective observational study

BACKGROUND

Low-acuity paediatric emergency department (PED) visits are common in high-income countries and are an increasing burden for the healthcare system and quality of care. Little is known about low-acuity PED visits in Switzerland. This study shows frequency and characteristics of such visits in two large PEDs in German-speaking and French-speaking regions of Switzerland.

METHODS

We conducted a retrospective observational study in the PED of two Swiss tertiary care hospitals, Bern and Lausanne. We extracted standardised administrative and medical data from the clinic information system for all PED visits of children aged 0-17 years from January to December 2018. We defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits.

RESULTS

We analysed 53 089 PED visits. The proportion of low-acuity visits was 54% (95% CI 53% to 54%, 28 556 visits). Low-acuity visits were associated with age younger than 5 years (adjusted OR, aOR 1.87, 95% CI 1.81 to 1.94), living within a 5 km radius of PED (aOR 1.27, 95% CI 1.22 to 1.32), and after hour presentations (weekends: aOR 1.14, 95% CI 1.10 to 1.18, nights: aOR 1.10, 95% CI 1.23 to 1.36).

CONCLUSION

Low-acuity visits are frequent in our PEDs and associated with younger age and convenience factors (proximity of residency and after hour presentation), pointing to a high demand for paediatric urgent care services in Switzerland not currently covered by the primary healthcare system.

Paediatric emergency department visits for non-urgent conditions: Can family medicine prevent this?

Background

In Turkey, family physicians serve only during office hours, while emergency services have 7/24 free access. Non-urgent patients commonly use Paediatric Emergency departments (PEDs). In Turkey, there is little evidence as to why emergency services are used instead of family medicine for non-urgent paediatric healthcare.

Objectives

To evaluate the causes and factors affecting non-urgent PED visits. To determine the reason for non-use of family medicine for non-urgent paediatric healthcare.

Methods

We conducted a cross-sectional study at Gaziantep University PED between April and May 2019. We administered a questionnaire to the parents of children (from one month to 16 years) triaged to non-urgent (level-5) using a 5-level triage system.

Results

A total of 457 parents were surveyed. The average patient age was 6.5 ± 4.7 years and 24.5% had a chronic disease. One-third of the parents (33.7%) considered their children’s condition ‘very urgent’. The most important reason for preferring PED (42.5%) instead of family physician or alternative health facilities was the thought that the condition of children would worsen. Two hundred fifty-three (55.4%) of the patients presented outside working hours. Although 58.9% of parents were satisfied with the family physician, most (67.8%) stated that they preferred other specialists rather than family physicians when the child had health problems. Fathers who were primary school graduates were more likely to prefer other specialists than family physicians.

Conclusion

Parents’ perception of urgency and the thought that their child’s condition will worsen are the main reasons for non-urgent using PED.

Assessing the Impact of COVID-19 Public Health Stages on Paediatric Emergency Attendance

This study outlines the impact of COVID-19 on paediatric emergency department (ED) utilisation and assesses the extent of healthcare avoidance during each stage of the public health response strategy. Records from five EDs and one urgent care centre in Ireland, representing approximately 48% of national annual public paediatric ED attendances, are analysed to determine changes in characteristics of attendance during the three month period following the first reported COVID-19 case in Ireland, with reference to specific national public health stages. ED attendance reduced by 27–62% across all categories of diagnosis in the Delay phase and remained significantly below prior year levels as the country began Phase One of Reopening, with an incident rate ratio (IRR) of 0.58. The decrease was predominantly attributable to reduced attendance for injury and viral/viral induced conditions resulting from changed living conditions imposed by the public health response. However, attendance for complex chronic conditions also reduced and had yet to return to pre-COVID levels as reopening began. Attendances referred by general practitioners (GPs) dropped by 13 percentage points in the Delay phase and remained at that level. While changes in living conditions explain much of the decrease in overall attendance and in GP referrals, reduced attendance for complex chronic conditions may indicate avoidance behaviour and continued surveillance is necessary.

Hospital-provision of essential primary care in 56 countries: determinants and quality

Objective

To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres.

Methods

We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data.

Findings

On average across 56 countries, public hospitals were used as the sole source of care by 16.9% of 126 012 women who obtained contraceptives, 23.1% of 418 236 women who received routine antenatal care, 19.9% of 47 677 children with diarrhoea and 18.5% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received.

Conclusion

As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.

Children's unscheduled primary and emergency care in Ireland: a multimethod approach to understanding decision making, trends, outcomes and parental perspectives (CUPID): project protocol

INTRODUCTION

The aim of this project is to determine the patterns, decision-making processes and parental preferences associated with unscheduled paediatric healthcare utilisation in Ireland. Unscheduled paediatric healthcare is outpatient care provided within primary care settings by general practitioners (GPs), emergency departments (EDs) located in paediatric and general hospitals, and out-of-hours services provided by cooperatives of GPs operating on a regional basis. This project will take a multimethod approach to analysing the utilisation of unscheduled paediatric healthcare nationally within the context of a significant change to the provision of healthcare for young children in Ireland-the introduction of free at the point of delivery GP care for all children aged under 6.

METHODS AND ANALYSIS

A multimethod approach consisting of three work packages will be employed. Using patient-level data, work package 1 will describe patterns of attendance at primary care, out-of-hours medical services and at EDs. Applying a difference-in-difference methodology, the impact of the introduction of free GP care for children under 6 on attendance will be assessed. Work package 2 will explore geospatial trends of attendance at EDs, identifying disparities in ED attendance by local area and demographic characteristics. Work package 3 will employ two discrete choice experiments to examine parental preferences for unscheduled paediatric healthcare and GP decision making when referring a child to the ED. The insights gained by each of the work packages individually and collectively will inform evidence-based health policy for the organisation of paediatric care and resource allocation.

ETHICS AND DISSEMINATION

Ethical approval for this research has been granted by University College Dublin, The Irish College of General Practitioners and the five participating hospitals. Results will be disseminated via publication in peer-reviewed journals, national and international conferences, and to relevant stakeholders and interest groups.

Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare - systematic review

INTRODUCTION

Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents' decision making when seeking unscheduled healthcare for their children. The systematic review question was "What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?"

METHOD

Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data.

RESULTS

Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent's perception that the child's condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP.

CONCLUSION

Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.

Adjacent Primary Care May Reduce Less Urgent Pediatric Emergency Department Visits

Aims: Pediatric emergency department (ED) overcrowding is a challenge. This study was designed to evaluate if a hospital-integrated primary care unit (HPCU) reduces less urgent visits at a pediatric ED. Methods: This retrospective cross-sectional study was carried out at a university hospital in Sweden, where the HPCU, open outside office hours, had been integrated next to the ED. Children seeking ED care during 4-week high- and low-load study periods before (2012) and after (2015) implementation of the HPCU were included. Information on patient characteristics, ED management, and length of ED stay was obtained from hospital data registers. Results: In total, 3216 and 3074 ED patient visits were recorded in 2012 and 2015, respectively. During opening hours of the HPCU, the proportions of pediatric ED visits (28% lower; P < .001), visits in the lowest triage group (36% lower; P < .001), patients presenting with fever (P = .001) or ear pain (P < .001), and nonadmitted ED patients (P = .033), were significantly lower in 2015 than in 2012, whereas the proportion of infants ≤3 months was higher in 2015 (P < .001). Conclusions: By enabling adjacent management of less urgent pediatric patients at adequate lower levels of medical care, implementation of a HPCU outside office hours may contribute to fewer and more appropriate pediatric ED visits.

Preventable admissions and emergency-department-visits in pediatric asylum-seeking and non-asylum-seeking patients

Background

Migrant health has become an essential part of public health. According to the World Health Organization, many health systems in Europe have not yet adapted adequately to the needs of asylum-seekers, which might result in untimely and inefficient health care for asylum-seeking patients. The aim of this study was to assess the number of preventable hospital admissions and emergency department visits in asylum-seeking and non-asylum-seeking pediatric patients.

Methods

This is a retrospective, hospital-based study. The study was done at the University Children’s Hospital Basel in Switzerland. Patients admitted or presenting to the emergency department were included and split into the groups of asylum-seeking and non-asylum-seeking patients.

All admissions and emergency-department visits were extracted from the administrative electronic health records from 1st Jan 2016-31st Dec 2017. The main outcome was the proportion of admissions due to ambulatory-care-sensitive conditions (which refer to conditions for which admission can be prevented by early interventions in primary care) in asylum-seeking and non-asylum-seeking patients. Ambulatory-care-sensitive conditions were defined by a validated list of ICD-10 codes.

The secondary objective was to assess the number of preventable emergency-department visits by asylum-seeking patients defined as proportion of visits with a non-urgent triage score.

Results

A total of 75′199 hospital visits were included, of which 63′405 were emergency department visits and 11′794 were admissions. Ambulatory-care-sensitive conditions accounted for 12.1% (18/149) of asylum-seeking and 10.9% (1270/11645) of non-asylum seeking patients’ admissions. Among the emergency department visits by asylum-seeking patients, non-urgent conditions accounted for 82.2% (244/297).

Conclusions

Admissions due to ambulatory-care-sensitive conditions are comparable in asylum-seeking and non-asylum-seeking children, suggesting few delayed presentations to ambulatory care facilities. Strategies to prevent non-urgent visits at pediatric emergency department facilities are needed.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making

Background

Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

Objective

To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

Design

Realist review.

Methods

Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.

Results

Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.

Conclusions

Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Background

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design

Mixed-methods sequential design.

Setting

Four counties in southern England coterminous with a NHS 111 provider area.

Methods

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration

This study is registered as UKCRN 32207.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Non-urgent paediatric emergency department presentation: A systematic review

There has been an increase in the use of the emergency department (ED) for non-urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non-urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non-urgent ED presentation in paediatric populations. Thirty-one articles met the inclusion criteria. The mean proportion of non-urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non-urgent ED use in paediatric populations. The findings of this review suggest that non-urgent ED use in paediatric populations is high. However, non-urgent ED use and the reasons for the visits in paediatric populations remain understudied.

The impact of an emergency care access point on pediatric attendances at the emergency department: An observational study

OBJECTIVE

Crowding is a growing concern in general and pediatric Emergency Departments (EDs). The Emergency Care Access Point (ECAP) - a collaboration between general practitioners and the ED - has been established to reduce the number of self-referrals and non-urgent ED visits. The aim of this study was to determine the impact of an ECAP on pediatric attendances in the ED.

METHODS

Retrospective analysis of 3997 pediatric patients who visited the ED of a regional teaching hospital in the Netherlands, one year before and one year after the implementation of an ECAP. Patient characteristics, presented complaints and diagnoses, throughput times, and follow-up between the study groups were compared, both during office hours and after-hours.

RESULTS

After ECAP implementation, a 16.3% reduction in pediatric ED visits was observed. ECAP implementation was associated with a decline in self-referrals by 97.2%. Presented complaints, ED diagnoses and acuity were similar pre- and post-ECAP. However, consultations and follow-up were required more frequently. The admission rate during nights increased (49.3% versus 64.0%). Overall admission rates were similar.

CONCLUSIONS

The implementation of an ECAP was associated with a reduction of pediatric ED use, including a considerable but expected decline in pediatric self-referrals. Patient acuity pre- and post-ECAP was similar. Our results suggest that this primary care intervention might help reduce the workload in a pediatric ED. Future studies are warranted to further investigate this hypothesis and to evaluate the impact of an ECAP in other healthcare settings. These future efforts need to include patient oriented outcomes.

Factors related to out-of-hours help-seeking for acute health problems: a survey study using case scenarios

Background

The acute out-of-hours healthcare services are challenged by increasing demand in many countries. We aimed to examine factors influencing the intended help-seeking in out-of-hours care for acute health problems during evenings, nights, and weekends.

Methods

We conducted a survey study based on data from parents of children (aged 0–4 years) and adults (aged 30–39 and 50–59 years) in Denmark, the Netherlands and Switzerland. Intended help-seeking behaviour was measured by six hypothetical case scenarios. We used Andersen’s Behavioural Model to categorise potentially influential factors and applied multiple binomial regression to assess the influence of selected factors.

Results

A total of 1015 parents and 2942 adults participated. We identified several significant influential factors. Parents holding a low education (OR 1.56), having migrant background (western: OR 1.23; non-western: OR 1.93), having one child (OR 1.24), perceiving few barriers to using out-of-hours primary care (OR 1.59), perceiving difficulties with organising childcare (OR 1.13), and having a history of frequent contacts with out-of-hours care (OR 1.55) were more inclined to contact out-of-hours care, whereas female (OR 0.85) and non-anxious parents (OR 0.77) were less inclined. Adults who were older (OR 1.01), holding a medical education (OR 1.13), having non-western background (OR 1.28), being unemployed (OR 1.17), perceiving few barriers to using out-of-hours primary care (OR 1.37), and having a history of frequent contacts with a GP (few: OR 1.15; more: OR 1.22) and/or with out-of-hours care (one: OR 1.20; more: OR 1.49) were more inclined to contact out-of-hours care, whereas adults with no or little social support (OR 0.84) and adults with high health literacy level on health information (OR 0.91) were less inclined. Dutch parents were less inclined than Danish parents to contact out-of-hours care (OR 0.62), whereas Swiss adults were more inclined than Danish adults to contact out-of-hours care (OR 1.16).

Conclusion

We identified several factors related to intended help-seeking in out-of-hours care. These results could be used to develop targeted interventions, but more research is needed to examine the underlying explanations for the identified differences.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6332-6) contains supplementary material, which is available to authorized users.

Socio-economic composition of low-acuity paediatric presentation at a regional hospital emergency department

AIM

Despite increasing rates of emergency department (ED) utilisation, little is known about low-acuity presentations in children ≤5 years. The aims of the study were to estimate the proportion and cost of low-acuity presentations in children ≤5 years presenting to the ED and to determine the relative effect of socio-economic status (SES) on paediatric low-acuity presentations at the ED.

METHODS

This is a retrospective observational study of children ≤5 years presenting to the Cairns Hospital ED over 4 years. A multivariate logistic regression model was used to assess the association between SES and low-acuity presentations. Cost of low-acuity presentations was calculated based on triage score and admission status, using costs obtained from the National Hospital Cost Data Collection.

RESULTS

A total of 23 086 children were included in the study, of whom 56.7% were male (mean age = 1.85 ± 1.63 years). Approximately one-third of ED visits were low-acuity presentations (32.4%), and low-acuity presentations increased progressively with SES. In multivariate analysis, children from families with very high SES were twice as likely to have a low-acuity presentation (odds ratio 2.17; 95% confidence interval, 1.66-2.85). Low-acuity ED presentations cost the health-care system in excess of A$895 000-A$1 110 000 per year.

CONCLUSIONS

These findings demonstrate that a significant proportion of paediatric ED visits are of low acuity and that these visits yield a substantial cost to the health system. Further research is required regarding care givers' rationale and potentially other reasons underlying these low-acuity ED presentations.

Do general practice patients with and without appointment differ? Cross-sectional study

BACKGROUND

Even in practices with a comprehensive appointment system a minority of patients walks in without prior notice, sometimes causing problems for practice service quality. We aimed to explore differences between patients consulting primary care practices with and without appointment.

METHODS

Consecutive patients visiting five primary care practices without an appointment and following patients with an appointment were asked to fill in a four-page questionnaire addressing socio-demographic characteristics, the reason for encounter, urgency of seeing a physician, depressive, somatic and anxiety symptoms, personality traits, and satisfaction with the practice. Physicians also documented the reason for encounter and assessed the urgency. Data were analyzed using univariate and multivariate methods.

RESULTS

Two hundred fifty-one patients without and 250 patients with appointment participated. Patients without appointment were significantly younger (mean age 44 vs. 50 years) and reported less often chronic diseases (29% vs. 45%). Also, reasons for encounter differed (e.g., 27% vs. 16% with a respiratory problem). Patients' ratings of urgency did not differ between groups (p = 0.46), but physicians rated urgency higher among patients without appointment (p < 0.001). In logistic regression analyses younger age, male gender, absence of chronic disease, positive screening for at least one mental disorder, low values on the personality trait openness for experience, a high urgency rating by the physician, and a respiratory or musculoskeletal problem as reason for encounter were significantly associated with a higher likelihood of being a patient without appointment.

CONCLUSIONS

In this study, younger age and a high urgency rating by physicians were the variables most consistently associated with the likelihood of being a patient without appointment. Overall, differences between patients seeking general practices with a comprehensive appointment system without prior notice and patients with appointments were relatively minor.

Barriers and enablers to a physician-delivered educational initiative to reduce low-acuity visits to the pediatric emergency department

BACKGROUND

Use of the pediatric emergency department (PED) for low-acuity health issues is a growing problem, contributing to overcrowding, longer waits and higher health system costs. This study examines an educational initiative aimed at reducing low-acuity PED visits. The initiative, implemented at an academic pediatric hospital, saw PED physicians share a pamphlet with caregivers to educate them about appropriate PED use and alternatives. Despite early impacts, the initiative was not sustained. This study analyzes the barriers and enablers to physician participation in the initiative, and offers strategies to improve implementation and sustainability of similar future initiatives.

METHODS

Forty-two PED physicians were invited to participate in a semi-structured individual interview assessing their views about low-acuity visits, their pamphlet use, barriers and enablers to pamphlet use, and the initiative's potential for reducing low-acuity visits. Suggestions were solicited for improving the initiative and reducing low-acuity visits. Constant comparative method was used during analysis. Codes were developed inductively and iteratively, then grouped according to the Theoretical Domains Framework (TDF). Efforts to ensure study credibility included seeking participant feedback on the findings.

RESULTS

Twenty-three PED physicians were interviewed (55%). Barriers and enablers for pamphlet use were identified and grouped according to five of the 14 TDF domains: social/professional role and identity; beliefs about consequences; environmental context and resources; social influences; and emotions.

CONCLUSIONS

The TDF provided an effective approach to identify the key elements influencing physician participation in the educational initiative. This information will help inform behavior change interventions to improve the implementation of similar future initiatives that involve physicians as the primary educators of caregivers.

Predicting Low-Resource-Intensity Emergency Department Visits in Children

OBJECTIVES

Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits.

METHODS

We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI.

RESULTS

Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74.

CONCLUSIONS

Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered.

Distance to the Pediatric Emergency Department and Nonurgent Visits in Friuli Venezia Giulia, Italy

OBJECTIVES

Our objective was to assess how the distance from home to the closest pediatric emergency department (ED) affects nonurgent emergency room visits among the child population of the Northeastern Italian region of Friuli Venezia Giulia.

METHODS

The study was based on the administrative databases of the Regional Health Information System of Friuli Venezia Giulia. For the year 2014, we abstracted the records of all white-triage-tag visits of children younger than 16 years from the databases of the 3 regional pediatric EDs located in the 3 main cities. Those records were individually linked to the regional population's georeferenced address database through an anonymous univocal identifier. For each child younger than 16 years living within 20 km from an ED, we calculated the linear distance between the ED and home address. Distances were grouped into 7 circular distance bands: less than 2, 2 to 4, 4 to 6, 6 to 8, 8 to 10, 10 to 15, and 15 to 20 km. Within each band, we calculated the rate of ED visits during the year.

RESULTS

In 2014, there were 12,055 white-triage-tag visits accounting for 24.7% of all visits in the regional pediatric EDs. Although the overall rate of ED visits was different among the EDs, it decreased significantly with increasing distance to the ED, with a 6-fold difference between the innermost and the outermost bands.

CONCLUSIONS

In Friuli Venezia Giulia, short distance is a prompter for inappropriate pediatric ED attendance. Further research is needed in this region to understand the parental standpoint to implement strategies promoting uniform behaviors within the regional boundaries.

Emergency department use by paediatric patients in Lombardy Region, Italy: a population study

OBJECTIVES

To estimate the rate of paediatric attendance at emergency departments (EDs) in the Lombardy Region, Italy, and to determine the factors contributing to different patterns of use.

METHODS

By analysing healthcare administrative databases, ED attendance by 1.6 million youths <18 years old during 2012 in the Lombardy Region was assessed. The pattern of use was categorised based on the number of ED visits and level of emergency, defined by triage code and outcome of the visit. Logistic regression analyses were performed to identify the characteristics of access for non-urgent reasons and those of patients with frequent non-urgent access (≥4 accesses for non-urgent reasons only). A case-control study was carried out to compare healthcare resource use by children 1-5 years old who were 'frequent non-urgent users' with that of randomly selected controls, matched by age, gender, nationality and primary care physician.

RESULTS

During 2012, 440 284 (27%) of children and adolescents had at least one ED attendance, with trauma (26%) and respiratory tract infections (22%) as the most frequent diagnoses. In all, 533 037 (79%) accesses were for non-urgent reasons, and 12 533 (3% of the ED users) were frequent non-urgent users. Male gender (OR 1.12; 95% CI 1.08 to 1.17), preschool age (OR 3.14; 95% CI 2.98 to 3.31) and place of residence (OR 1.74; 95% CI 1.70 to 1.99) were associated with a higher risk of being a frequent non-urgent user. Moreover, a greater healthcare consumption was observed in this group.

CONCLUSIONS

One out of four children and adolescents attended the ED at least once per year, 3% of whom were frequent non-urgent users, with a high overall healthcare resource consumption.

Preschool children in out-of-hours primary care - a questionnaire-based cross-sectional study of factors related to the medical relevance of health problems

Background

Out-of-hours primary care (OOH-PC) is intended to provide medical care services for health problems that cannot wait until normal office hours. Children under five years of age represent about 19% of all OOH-PC contacts in Denmark, and the frequency of calls assessed as severe by health professionals is markedly lower for children than for other age groups. Several studies have questioned the appropriateness of the parents’ use of OOH-PC. We aimed to identify factors associated with calls from parents of pre-school children concerning perceived non-severe health problems that were ranked by the triaging GPs as more appropriate for GP office hours (defined as ‘medically irrelevant’).

Methods

We used data from a cross-sectional study performed in the Central Denmark Region for a 1-year period during 2010–2011. GPs in the OOH-PC assessed random contacts, and a questionnaire was subsequently sent to registered patients. Associations between different factors and the medical irrelevance of contacts were estimated with a generalised linear model to calculate the prevalence ratio (PR).

Results

Among all included 522 telephone consultations and 1226 face-to-face consultations, we identified 71 (13.6%) telephone consultations and 95 (7.8%) face-to-face consultations that were both assessed as non-severe by the parents and more appropriate for GP office hours by the GPs. For telephone consultations, contacts at other times than 4–8 pm on weekdays were statistically significantly associated with medical irrelevance. Additionally, symptoms of longer duration than 24 h were statistically significantly associated medical irrelevance.

Conclusions

A large part of the calls to the Danish OOH-PC concern children. The results indicate that some of these calls are made for other than strictly medical reasons. To achieve more effective use of available resources, it might seem relevant to aim at directing more contacts directly to daytime care. However, future studies to enhance our knowledge on parents’ motivation and behaviour would be recommendable.

A tale of two systems: practice patterns of a single group of emergency medical physicians in Taiwan and China

Background

The quality of pediatric emergency care has been a major concern in health care. Following a series of health system reforms in China, it is important to do this assessment of pediatric emergency care, and to explore potential influences of health care system. This study aimed to compare practice differences in treating children with respiratory illnesses in two emergency department (ED) settings within different health care systems: China and Taiwan.

Methods

A pooled cross-sectional hospital-based study was conducted in two tertiary teaching hospitals in Xiamen, China and Keelung, Taiwan belong to the same hospital chain group. A team of 21 pediatricians rotated between the EDs of the two hospitals from 2009 to 2012. There were 109,705 ED encounters treated by the same team of pediatricians and 6596 visits were analyzed for common respiratory illnesses. Twelve quality measures in process and outcomes of asthma, bronchiolitis and croup were reported. Descriptive statistics and multiple logistic regression models were applied to assess. In order to demonstrate the robustness of our findings, we analyzed the data using an alternative modeling technique, multilevel modeling.

Results

After adjustment, children with asthma presented to the ED in China had a significantly 76% lower likelihood to be prescribed a chest radiograph, and a 98% lower likelihood to be prescribed steroids and discharged home than those in Taiwan. Also, children with asthma presented to the ED in China had significantly 7.76 times higher risk to incur 24-72 h return visits. Furthermore, children with bronchiolitis in China (Odds ratio (OR): 0.21; 95% Confidence interval (CI): 0.17-0.28) were significantly less likely to be prescribed chest radiograph, but were significantly more likely to be prescribed antibiotics (OR: 2.19; 95% CI: 1.46-3.28).

Conclusions

This study illustrated that although high quality care depends on better assessment of physician performance, the delivery of pediatric emergency care differed significantly between these two healthcare systems after holding the care providers the same and adjusting for important patient characteristics. The findings suggest that the features of the health care system may play a significant role.

Frequent users of the pediatric emergency department

OBJECTIVES

Emergency department (ED) crowding is associated with increased morbidity and mortality. Its etiology is multifactorial, and frequent ED use (defined as more or equal to five visits per year) is a major contributor to high patient volumes. Our primary objective is to characterize the frequent user population. Our secondary objective is to examine risk factors for frequent emergency use.

METHODS

We conducted a retrospective cohort study of pediatric emergency department (PED) visits at the Montreal Children's Hospital using the Système Informatique Urgence (SIURGE), electronic medical record database. We analysed the relation between patient's characteristics and the number of PED visits over a 1-year period following the index visit.

RESULTS

Patients totalling 52,088 accounted for 94,155 visits. Of those, 2,474 (4.7%) patients had five and more recurrent visits and accounted for 16.6% (15,612 visits) of the total PED visits. Lower level of acuity at index visit (odds ratio [OR] 0.85) was associated with a lower number of recurrent visits. Lower socioeconomic status (social deprivation index OR 1.09, material deprivation index OR 1.08) was associated with a higher number of recurrent visits. Asthma (OR 1.57); infectious ear, nose, and sinus disorders (OR 1.33); and other respiratory disorders (OR 1.56) were independently associated with a higher incidence of a recurrent visit within the year following the first visit.

CONCLUSION

Our study is the first Canadian study to assess risk factors of frequent pediatric emergency use. The identified risk factors and diagnoses highlight the need for future evidence-based, targeted innovative research evaluating strategies to minimize ED crowding, to improve health outcomes and to improve patient satisfaction.

Presentation to Emergency Departments for Acute Rhinosinusitis

Objective

Medicaid and self-pay insurance statuses and race are associated with emergency department (ED) presentation for uncomplicated acute rhinosinusitis (ARS). We investigated whether ARS symptomatology could explain this disproportionate ED use.

Study Design

2006-2010 National Hospital Ambulatory Medical Care Surveys.

Setting

EDs in the United States.

Subjects and Methods

The data comprise 1,632,826 adult visits for uncomplicated ARS at hospital EDs. Patient-reported reasons for presentation included constitutional symptoms, facial pain or headache, sinonasal symptoms, head cold or flu-like symptoms, cough or sputum production, and sore throat. Patient-reported pain level was also included. Symptoms were assessed for associations with insurance status and race after controlling for clinical, demographic, and socioeconomic characteristics.

Results

Medicaid patients had similar symptomatology and levels of pain when compared with privately insured patients. Self-pay patients reported higher pain levels ( P = .033) and were less likely to report head cold or flu-like symptoms ( P = .018) but were equally likely to report other symptomatology. Relative to white patients, Hispanic patients were more likely to complain of facial pain and headaches ( P = .033) and less likely to complain of other classical ARS symptoms, such as cough or sputum production ( P = .013), sinonasal symptoms ( P = .019), or head cold or flu-like symptoms ( P = .019). Black patients were also less likely to complain of sinonasal symptoms ( P = .038).

Conclusion

Symptomatology does not explain disproportionate ED use for ARS by Medicaid patients, while higher self-reported pain levels may explain self-pay patients’ disproportionate ED utilization. Likewise, ED presentation for ARS among Hispanic patients may be related to symptomatology that is less specific for ARS, such as headache and facial pain.

Pediatric pre-hospital emergencies in Belgium: a 2-year national descriptive study

This study aims to describe the pediatric physician-staffed EMS missions at a national level and to compare the pediatric and the adult EMS missions. Using a national database, we analyzed 254,812 interventions including 15,294 (6 %) pediatric emergencies. Less children than adults received an intravenous infusion (52.7 versus 77.1 %, p < 0.001), but the intra-osseous access was used more frequently in children (1.3 versus 0.8 %, p < 0.001). More children than adults benefited from a therapeutic immobilization (16.3 versus 13.2 %, p < 0.001). Endotracheal intubation was rare in children (2.1 %) as well as cardiopulmonary resuscitation (1.2 %). Children were more likely than adults to suffer from a neurological problem (32.4 versus 21.3 %, p < 0.001) or from a trauma (27.1 versus 16.8 %, p < 0.001). The prevalence of the pediatric diagnoses showed an age dependency: the respiratory problems were more prevalent in infants (40.3 % of the 0-12-months old), 52.1 % of the 1-4-year-old children suffered from a neurological problem, and the prevalence of trauma raised from 14.8 % of the infants to 47.1 % of the 11-15 year olds.

CONCLUSION

Pre-hospital pediatric EMS missions are not frequent and differ from the adult interventions. The pediatric characteristics highlighted in this study should help EMS teams to be better prepared to deal with sick children in the pre-hospital setting.

WHAT IS KNOWN

• Pediatric and adult emergencies differ. • Pediatric life-threatening emergencies are not frequent. What is New: • This study is the first to describe a European national cohort of pediatric physician-staffed EMS missions and to compare the pediatric and the adult missions at a national level. • This large cohort study confirms scarce regional data indicating that pediatric pre-hospital emergencies are not frequent and mostly non-life-threatening.

Paediatric emergency department referrals from primary care

Background Over the last decade, paediatric referrals from general practitioners (GPs) to the emergency department (ED) have increased by 60% in Australia. Objective To investigate the characteristics of Victorian children referred by GPs to the ED with lower-urgency conditions. Method Data were collected from four hospital EDs in Victoria, May–November 2014. Parents attending the ED with their child triaged as lower urgency were surveyed. Descriptive, frequency, and bivariate analyses were performed. Results Of the 1150 responses, 28% (320) visited their GP before attending ED. Of these 66% (212), were referred by their GP. A greater proportion with injury than illness (84% vs 59%; P < 0.0001) was referred to the ED if they had first visited their GP. Conclusion Motivations of GPs to send lower-urgency injured and ill children to ED are not well understood. The high number of referrals from GPs to the ED for lower urgency conditions suggests attention by policy makers and health professionals must be paid to the current patterns of care of children in general practice. What is known about the topic? Paediatric referrals in Australia from GPs to EDs have increased in the last decade, along with the absolute number of children in Victoria presenting to the ED. What does this paper add? A significant number of children (66%) who attend the GP before visiting the ED are referred to the ED for their lower urgency condition. What are the implications for practitioners? It may be appropriate for GPs to be further supported to manage lower urgency conditions, through better resources or education.

Point-of-care testing with CRP in primary care: a registry-based observational study from Norway

Background

Norwegian primary health care is maintained on the regular general practitioners (RGPs), GP’s contracted to the municipalities in a list patient system, working at daytime and at out-of-hours services (OOH services). Respiratory disease is most prevalent during OOH services, and in more than 50 % of the consultations, a CRP test is performed. Children in particular have a high consultation rate, and the CRP test is frequently conducted, but the contributing factors behind its frequent use are not known. This study compares the RGPs rate of CRP use at daytime and OOH in consultations with children and how this rate is influenced by characteristics of the RGPs.

Methods

A cross-sectional register study was conducted based on all (N = 2 552 600) electronic compensation claims from consultations with children ≤ 5 year during the period 2009–2011 from primary health care. Consultation rates and CRP use were estimated and analysed using descriptive methods. Being among the 20 % of RGPs with the highest rate of CRP use at daytime or OOH was an outcome measure in regression analyses using RGP-, and RGP list characteristics as explanatory variables.

Results

One third of all RGPs work regularly in OOH services, and they use CRP 1.42 times more frequently in consultations with children in OOH services than in daytime services even when the distribution of diagnosis according to ICPC-2 chapters is similar. Not being approved specialist, have a large number at their patient-lists but relatively few children on their list and a large number of consultations with children were significantly associated with frequent use of CRP in daytime services. The predictors for frequent CRP use in OOH services were being a young doctor, having many consultations with children during OOH and a frequent use of CRP in daytime services.

Conclusions

The increase in the frequency of CRP test use from daytime to OOH occurs in general for RGPs and for all most used diagnoses. The RGPs who use the CRP test most frequently in their daytime practice have the highest rate of CRP in OOH services.