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Zynda AJ, Loftin MC, Pollard-McGrandy A, Covassin T, Eke R, Wallace J. Geographic characteristics of sport- and non-sport-related concussions presenting to emergency departments in the United States. JOURNAL OF SAFETY RESEARCH 2024; 89:26-32. [PMID: 38858049 DOI: 10.1016/j.jsr.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/11/2023] [Accepted: 01/16/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Concussion is a type of traumatic brain injury (TBI) that can be sustained through sport-related and non-sport-related (e.g., motor vehicle accidents, falls, assaults) mechanisms of injury (MOI). Variations in concussion incidence and MOI may be present throughout the four geographic regions (Midwest, Northeast, South, West) of the United States. However, there is limited evidence exploring concussion cause and diagnosis patterns based on geographic region and MOI. These factors have implications for better understanding the burden of concussion and necessary efforts that can translate to the mitigation of safety concerns. PURPOSE The purpose of this study was to identify patterns of sport-related concussion (SRC) and non-sport-related concussion (NSRC) across the four geographic regions of the United States. METHODS A descriptive epidemiology study of patient visits to the emergency department (ED) for concussion between 2010 and 2018, using publicly available data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) was conducted. The exposure of interest was geographic region while the main outcome measures were concussion diagnosis and MOI. Descriptive statistics were calculated using population-weighted frequencies and percentages. The association between geographic region and MOI (SRC vs. NSRC) was analyzed using logistic regression models. Odds ratios (OR) presented with 95% confidence intervals (CI) were included. Univariate analyses were conducted followed by multivariable analyses adjusting for sex, age, race/ethnicity, and primary source of payment. Statistical significance was set a priori at p < 0.05 for all analyses. RESULTS From 2010 to 2018, 1,161 visits resulted in a concussion diagnosis, representing an estimated 7,111,856 visits nationwide. A greater proportion of concussion diagnoses occurred within EDs in the South (38.2%) followed by the West (25.8%), Midwest (21.4%), and Northeast (14.6%). Compared to the West region, patients visiting the ED in the Midwest (OR = 0.75, 95% CI = 0.57-0.98) and Northeast (OR = 0.71, 95% CI = 0.51-0.98) had a lower odds of being diagnosed with a concussion. More patients sustained a NSRC MOI (94.3%) compared to SRC MOI (5.7%). For both mechanisms, the South region had the highest population-weighted frequency of SRC (n = 219,994) and NSRC diagnoses (n = 2,495,753). Univariate and multivariable logistic regression analyses did not reveal statistically significant associations for geographic region and MOI (p > 0.05). CONCLUSION Our findings showed that the Midwest and Northeast regions had a lower odds of concussion diagnoses in EDs. Overall, the vast majority of concussions were not sport-related, which has public health implications. These findings improve our understanding of how concussion injuries are being sustained geographically nationwide and help to explain care-seeking patterns for concussion in the ED setting.
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Affiliation(s)
| | | | | | | | - Ransome Eke
- Mercer University School of Medicine, Columbus, GA, USA
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Amjad S, Tromburg C, Adesunkanmi M, Mawa J, Mahbub N, Campbell S, Chari R, Rowe BH, Ospina MB. Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies. Ann Emerg Med 2024; 83:291-313. [PMID: 38069966 DOI: 10.1016/j.annemergmed.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 03/24/2024]
Abstract
STUDY OBJECTIVE Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations. METHODS This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses. RESULTS Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission. CONCLUSION Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.
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Affiliation(s)
- Sana Amjad
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Courtney Tromburg
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Maryam Adesunkanmi
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Jannatul Mawa
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Nazif Mahbub
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Sandra Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Radha Chari
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maria B Ospina
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada; Department of Public Health Sciences, Queen's University; Kingston, Ontario, Canada.
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Kannikeswaran N, Spencer P, Carcone A, Huth M, Mehmood Y, Ellis D. Utilization of electronic portal referrals to a community agency for children presenting with an asthma exacerbation to a pediatric emergency department. J Asthma 2024; 61:307-312. [PMID: 37847783 PMCID: PMC10939958 DOI: 10.1080/02770903.2023.2272796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/15/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE To evaluate referral rates and factors associated with referrals to a community agency for children evaluated for an asthma exacerbation at a pediatric emergency department (PED) and compare PED visits for asthma the following year between those referred and not referred. METHODS We reviewed electronic health records of children 2-18 years evaluated in our PED from 01/01/2019 to 12/31/2019 with an ICD-10 diagnostic code for asthma (J45x) following the introduction of a portal where clinicians could refer children to a community agency focused on improving health outcomes for asthma. We abstracted data on demographics, PED visits, and hospitalizations and used multivariate logistic regression to evaluate factors associated with referrals. RESULTS Of the 2262 charts analyzed, the majority of patients were male (61%), Black (76%), and held public insurance (71%). Only a minority of patients (n = 140, 6%) were referred. Age [6-12 years (AOR: 1.93, 95% CI: 1.21-3.08, p = .006), 13-18 years (AOR: 10.61, 95% CI: 6.53-17.24, p = .001)] and lifetime number of PED asthma visits [≥3 visits (AOR: 1.91, 95% CI, 1.01-3.62, p = .05)] were associated with referral. There was no significant difference in the mean number of PED visits in one year [referred: 0.59 (SD1.2) vs. not referred: 0.79 (SD1.3), t = 1.70, p = .09] between the two groups. CONCLUSION The referral rate to community agency from PED for asthma is low. There was no difference in short-term PED utilization for asthma between those referred and not referred.
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Affiliation(s)
- Nirupama Kannikeswaran
- Division of Emergency Medicine, Department of Pediatrics and Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Priya Spencer
- Division of Emergency Medicine, Children's Hospital of Michigan, Detroit, MI, USA
| | - April Carcone
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Marissa Huth
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yasir Mehmood
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Deborah Ellis
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA
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Giannouchos TV, Ukert B, Pirrallo RG, Smith J, Kum HC, Wright B, Dietrich A. Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States. Acad Pediatr 2024; 24:442-450. [PMID: 37673206 DOI: 10.1016/j.acap.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 07/11/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE This study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults. METHODS We conducted a retrospective secondary analysis using the 2012-2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0-19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals' characteristics using multivariable logistic regression models. RESULTS Among 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3-5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions. CONCLUSIONS Clinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.
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Affiliation(s)
- Theodoros V Giannouchos
- Department of Health Policy & Organization (TV Giannouchos), School of Public Health, The University of Alabama at Birmingham, Birmingham, Ala.
| | - Benjamin Ukert
- Department of Health Policy and Management (B Ukert, H-C Kum), School of Public Health, Texas A and M University, College Station, Tex
| | - Ronald G Pirrallo
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
| | - Jeremiah Smith
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
| | - Hye-Chung Kum
- Department of Health Policy and Management (B Ukert, H-C Kum), School of Public Health, Texas A and M University, College Station, Tex
| | - Brad Wright
- Department of Health Services Policy and Management (B Wright), Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Ann Dietrich
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
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Shukla M, Carcone A, Mooney M, Kannikeswaran N, Ellis DA. Evaluating barriers and facilitators to healthcare providers' use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework. J Asthma 2024; 61:184-193. [PMID: 37688796 PMCID: PMC10922072 DOI: 10.1080/02770903.2023.2257318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/16/2023] [Accepted: 09/05/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services. METHODS The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis. RESULTS Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers. CONCLUSIONS Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.
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Affiliation(s)
| | - April Carcone
- Family Medicine, Wayne State University, Detroit, MI, USA
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Atabaki SM, Shur NE, Munoz RA, Bhuvanendran S, Sable C, Rojas CR, Lopez-Magallon AJ, Clarke JC, Sabouriane CE, Krishnan A, Wessel DL. Direct-to-patient telemedicine: Expanding access to regional pediatric specialty care. J Investig Med 2024; 72:248-255. [PMID: 38102744 DOI: 10.1177/10815589231222197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Telemedicine is seen as a useful tool in reducing gaps in health care but this technology-enabled care can also exacerbate health inequity if not implemented with a focus on inclusivity. Though many studies have reported improvements as well as exacerbation of disparities in access to care in their telehealth programs, there does not exist a common evaluation tool to assess these programs. To mitigate the impact of COVID-19 on health care workers and protect medically vulnerable children, in March 2020 we expanded our pre-established specialty and subspecialty direct-to-patient pediatric telemedicine program in a high volume urban pediatric health system. Our program aimed to prevent disparities in pediatric health care. In this study, using a "Pillars of Access" approach as a model to evaluate impact and access to care of our direct-to-patient telemedicine program, we analyzed the patients that were seen pre-COVID versus post-COVID. Our study demonstrated an increase in telemedicine visits for patients from diverse socioeconomic and racial backgrounds, and geographically underserved communities. We also observed an increase in telemedicine visits for mental health complaints and for certain categories of high-risk patients. This study was not designed to identify language and cultural barriers to telemedicine. Future identification of these specific barriers is needed. The tool to evaluate telehealth impact/access to care through a "Pillars of Access" approach presented here could serve as a model for implementation of telehealth programs. Our study highlights telemedicine programs as a mechanism to address healthcare inequity and overcome barriers to care.
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Affiliation(s)
| | | | | | | | - Craig Sable
- Children's National Hospital, Washington, DC, USA
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Hart R, Feygin Y, Kluthe T, Quinn KG, Rao S, Baumer-Mouradian SH. Emergency departments: An underutilized resource to address pediatric influenza vaccine coverage. Vaccine 2023; 41:7026-7032. [PMID: 37865600 DOI: 10.1016/j.vaccine.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Emergency department (ED) based influenza vaccine (IV) programs have been successful in adults; however, little is known about pediatric ED IV programs in terms of prevalence, feasibility, or successful implementation. AIMS To describe the reach and effectiveness of IV practices in pediatric EDs, and identify IV facilitators and barriers. METHODS We assessed, via cross-sectional survey of pediatric ED physicians, number of EDs offering IV to children, vaccines administered annually, and perceived facilitators/barriers to vaccination. The proportion of EDs offering IV is reported. Chi-square tests compared facilitators and barriers among high performers (≥50 IV/year), low performers (<50 IV/yr), and non-vaccinators. We calculated an area of missed effect for the number of children who could be vaccinated if non-vaccinating EDs offered IV. RESULTS Among 492 physicians from 166 EDs, 142 responded (representing 61 (37.3 %) EDs). Most EDs were in large, urban, academic, freestanding children's hospitals (Table 1). Only twenty-six EDs (44.3 %) offer ≥ 1 IV/yr. Seventeen (65.4 %) were low performers, five (19.2 %) high performers, and four (15.4 %) were model programs. High/model performers used establish workflows more commonly than lower performers (78 % vs. 33 %), although this was not statistically significant (p = 0.077). Common facilitators included: strong provider and administration buy-in, electronic health record facilitation, storage/accessibility, and having a leadership team/champion (Fig. 1). Non-vaccinators commonly perceived lack of these factors as barriers. Many (24/61, 39.3 %) EDs expressed interested in establishing or growing IV programs. Up to 18,250 unvaccinated children could receive IV annually if non-vaccinating EDs offered IV during influenza season. CONCLUSIONS Over half of EDs participating in the Pediatric Emergency Medicine Collaborative Research Committee do not currently offer pediatric IV. Addressing identified barriers/facilitators to develop IV programs in EDs has potential to improve vaccination rates, especially among minority and underserved children.
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Affiliation(s)
- Rebecca Hart
- Department of Pediatrics, Norton Children's and the University of Louisville School of Medicine, 571 S. Floyd Street, Suite 412, Louisville, KY 40202, United Sates.
| | - Yana Feygin
- Department of Pediatrics, Norton Children's and the University of Louisville School of Medicine, 571 S. Floyd Street, Suite 412, Louisville, KY 40202, United Sates
| | - Theresa Kluthe
- Department of Pediatrics, Norton Children's and the University of Louisville School of Medicine, 571 S. Floyd Street, Suite 412, Louisville, KY 40202, United Sates
| | - Katherine G Quinn
- Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine, United Sates
| | - Suchitra Rao
- University of Colorado School of Medicine and Children's Hospital Colorado, United Sates
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O'Connell CP, Johnson KJ, Brown DS. Pediatric cancer patient emergency department visits and disposition by sociodemographic and economic characteristics. Pediatr Blood Cancer 2023; 70:e30636. [PMID: 37638808 DOI: 10.1002/pbc.30636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Limited research has been conducted on cancer-related emergency department (ED) patterns among pediatric cancer patients, including whether there are differences in the characteristics of individuals who seek ED care for cancer complications. The objectives of this study were to determine whether rates and disposition of cancer-related ED visits and hospital admissions in childhood cancer patients differ by sociodemographic factors. METHODS A cross-sectional analysis of ED encounters with a cancer diagnosis code among patients aged 0-19 years from the 2019 National Emergency Department Sample (NEDS) was conducted. Weighted logistic regression models were utilized to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for a primary cancer-related encounter, and hospital admission overall and by subgroup characteristics. RESULTS Of the unweighted 6,801,711 ED encounters in children aged 0-19 years, 10,793 were classified as visits by cancer patients. ED encounters of Hispanic versus non-Hispanic White pediatric cancer patients had higher odds of having a cancer-related primary diagnosis (OR = 1.15, 95% CI: 1.04-1.27). ED encounters of non-Hispanic Black pediatric patients and those in the lowest zip code income quartile had higher odds of hospital admission (OR = 1.28, 95% CI: 1.08-1.53; OR = 1.30, 95% CI: 1.15-1.46), while rurality was associated with lower odds of hospital admission (OR = 0.69, 95% CI: 0.57-0.83). CONCLUSION These results suggest that pediatric cancer patients from certain under-resourced communities are more likely to use the ED for cancer treatment complications, and their encounters are more likely to result in admission to the hospital.
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Affiliation(s)
| | - Kimberly J Johnson
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
- Siteman Cancer Center, Washington University in St Louis, St. Louis, Missouri, USA
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
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Hart R, Feygin Y, Kluthe T, Quinn K, Rao S, Baumer-Mouradian SH. Emergency Departments: An Underutilized Resource for Expanding COVID-19 Vaccine Coverage in Children. Vaccines (Basel) 2023; 11:1445. [PMID: 37766122 PMCID: PMC10536917 DOI: 10.3390/vaccines11091445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/16/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
COVID-19 vaccine (CV) acceptance rates remain suboptimal in children. Emergency departments (EDs) represent a unique opportunity to improve vaccination rates, particularly in underserved children. Little is known about the presence or reach of CV programs in US EDs. We assessed, via a cross-sectional survey of pediatric ED physicians, the number of EDs offering CVs to children, the approximate numbers of vaccines administered annually, and the perceived facilitators/barriers to vaccination. The proportion of EDs offering CVs is reported. Chi-square tests compared facilitators and barriers among frequent vaccinators (≥50 CVs/year), infrequent vaccinators (<50 CVs/year), and non-vaccinators. Among 492 physicians from 166 EDs, 142 responded (representing 61 (37.3%) EDs). Most EDs were in large, urban, academic, freestanding children's hospitals. Only 11 EDs (18.0%) offer ≥1 CV/year, and only two (18.2%) of these gave ≥50 CVs. Common facilitators of vaccination included the electronic health record facilitation of vaccination, a strong provider/staff buy-in, storage/accessibility, and having a leadership team or champion. Barriers included patient/caregiver refusal, forgetting to offer vaccines, and, less commonly, a lack of buy-in/support and the inaccessibility of vaccines. Many (28/47, 59.6%) EDs expressed interest in establishing a CV program.
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Affiliation(s)
- Rebecca Hart
- Department of Pediatrics, Norton Children’s and the University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Yana Feygin
- Department of Pediatrics, Norton Children’s and the University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Theresa Kluthe
- Department of Pediatrics, Norton Children’s and the University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Katherine Quinn
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Suchitra Rao
- Department of Pediatrics (Infectious Diseases and Hospital Medicine), University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Shannon H. Baumer-Mouradian
- Department of Pediatrics, Medical College of Wisconsin/Children’s Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Frey SM, Rowe RK, Halterman JS. The prevalence of childhood asthma: interpreting falling rates in the context of shifting measurement and the COVID-19 pandemic. Curr Opin Pulm Med 2023; 29:197-201. [PMID: 36917214 PMCID: PMC10090305 DOI: 10.1097/mcp.0000000000000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
PURPOSE OF REVIEW The estimated prevalence of childhood asthma in the United States, as measured by the National Health Information Survey (NHIS), has decreased by 30% since 2017. This review provides context for observed changes in asthma rates by describing recent shifts in NHIS data collection and analysis, and considers whether the COVID-19 pandemic might impact asthma prevalence in years to come. RECENT FINDINGS The NHIS underwent a planned redesign in 2019 with updated sampling weights to better match the U.S. population. In early 2020, the COVID-19 pandemic resulted in unplanned modifications to NHIS implementation, which may have included fewer children from populations at a heightened risk for asthma. Decreasing prevalence estimates in recent years are likely at least in part due to these survey changes rather than true epidemiologic shift. However, pandemic-related changes to risk factors for childhood asthma (including exposure to rhinovirus infections and allergic sensitization) may also influence prevalence in the future. SUMMARY Recent changes in estimated rates of childhood asthma in the USA are likely driven by changes to survey methods and implementation, both before and during the COVID-19 pandemic. Additional years of data are needed to determine whether a true shift in disease prevalence is occurring.
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Affiliation(s)
- Sean M Frey
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Ghani F, Wang H, Manning SE, Sambamoorthi U. Interactive association of chronic illness and food insecurity with emergency department utilization among school-age children in the United States: A cross-sectional study. Health Sci Rep 2023; 6:e1123. [PMID: 36814967 PMCID: PMC9940462 DOI: 10.1002/hsr2.1123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/23/2023] Open
Abstract
Background and Aims Food insecurity combined with chronic disease conditions is a risk factor for Emergency Department (ED) utilization, an indicator of poor quality of care. However, such an association is not certain among school-age children with chronic conditions. Therefore, we aim to determine the association of food insecurity, chronic conditions, and ED utilization among school-age children in the United States. Methods We analyzed the data from the 2017 Medical expenditure panel survey (MEPS) among children aged 6-17 years (N = 5518). MEPS data was released electronically by the Agency for Healthcare Research and Quality (AHRQ). We identified four groups of school-age children based on the presence of food security and chronic conditions: 1) with food insecurity and chronic conditions; 2) no food insecurity and chronic conditions; 3) with food insecurity and no chronic conditions; and 4) no food insecurity and no chronic conditions. We compared ED utilization among these four groups using incidence rate ratios (IRR) after adjusting children's age, sex, race and ethnicity, household income, insurance coverage, obesity, and geographic region using count data model, specifically multivariable Poison regression. We used SAS 9.4 and STATA 14.2 for all the data analyses. Results There were unweighted 5518 school-age children who represented weighted 50,479,419 school-age children in the final analysis. Overall, 6.0% had food insecurity with chronic conditions. These children had higher ED utilization (19.7%) than the other three groups (13.3%, 8.8%, and 7.2%, p < 0.001). The adjusted IRR of ED utilization among school-age children with food insecurity and chronic conditions was 1.90 (95% confidence interval 1.20-3.01, p = 0.007) compared with those with food security and chronic conditions. Conclusion One in 16 school-age children has both food insecurity and chronic conditions. Food insecurity was positively associated with frequent ED visits in the presence of chronic conditions. Therefore, addressing food insecurity may reduce the risk of ED visits.
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Affiliation(s)
- Farheen Ghani
- Department of Pharmacotherapy, College of PharmacyUniversity of North Texas Health Science CenterFort WorthTexasUSA
| | - Hao Wang
- Department of Emergency MedicineJPS Health NetworkFort WorthTexasUSA
| | | | - Usha Sambamoorthi
- Department of Pharmacotherapy, College of PharmacyUniversity of North Texas Health Science CenterFort WorthTexasUSA
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Postdischarge Racial and Ethnic Disparities in Pediatric Appendicitis: A Mediation Analysis. J Surg Res 2023; 282:174-182. [PMID: 36308900 DOI: 10.1016/j.jss.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Significant racial and ethnic disparities exist for children presenting with acute appendicitis; however, it is unknown if disparities persist after initial management and hospital discharge. MATERIALS AND METHODS We performed a retrospective cohort study of children (aged < 18 y) who underwent treatment for acute appendicitis in 47 U.S. Children's Hospitals between 2017 and 2019. Primary outcomes were 30-d emergency department (ED) visits and 30-d inpatient readmission. Hierarchical multivariable logistic regression models were developed to determine the association of race and ethnicity on the primary outcomes. Inverse odds-weighted mediation analyses were used to estimate the degree to which complicated disease, insurance status, urbanicity, and residential socioeconomic status- mediated disparate outcomes. RESULTS A total of 67,303 patients were included. Compared with Non-Hispanic White children, Non-Hispanic Black (NHB) (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.23-1.59) and Hispanic/Latinx (HL) children (OR 1.55, 95% CI 1.44-1.67) had higher odds of ED visits. Only NHB children had higher odds of readmission (OR 1.43, 95% CI 1.30-1.57). On a multivariable analysis, NHB (adjusted OR 1.19, 95% CI 1.04-1.36) and HL (adjusted OR 1.19, 95% CI 1.09-1.31) children had higher odds of ED visits. Insurance, disease severity, socioeconomic status, and urbanicity mediated 61.6% (95% CI 29.7-100%) and 66.3% (95% CI 46.9-89.3%) of disparities for NHB and HL children, respectively. CONCLUSIONS Children of racial and ethnic minorities are more likely to visit the ED after treatment for acute appendicitis, but HL patients did not have a corresponding increase in readmission. These differences were mediated mainly by insurance status and urban residence. A lack of appropriate postdischarge education and follow-up may drive disparities in healthcare utilization after pediatric appendicitis.
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Davis E, Fagnano M, Halterman JS, Frey SM. Utilization of the emergency department as a routine source of care among children with asthma. J Asthma 2022; 60:1377-1385. [PMID: 36399630 DOI: 10.1080/02770903.2022.2149409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objective: To describe characteristics of children with persistent asthma in the ED who receive most of their healthcare in emergency settings; and determine whether recent asthma experiences or historic patterns of care are associated with identifying the ED as a typical location for care.Methods: We conducted a sub-analysis of baseline data from Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED), an RCT of children (3-12 years) presenting to the ED with persistent asthma (2016-2020). Caregivers identified reasons for seeking emergency care, including if their child received most overall healthcare in the ED ('ED Care'; primary outcome) or not ('Other Care'). Independent variables included demographics, recent symptoms and quality of life (QOL), and historic preventive care and healthcare use. We compared responses between ED Care and Other Care groups using bivariate and multivariate analyses.Results: We analyzed data for 355 children (31% ED Care, 69% Other Care). Compared with Other Care, ED Care respondents were more likely to identify the ED as the closest source of healthcare; report fewer symptom nights but a poorer quality of life; and describe the ED as a usual place for sick care, despite most having a PCP.Conclusions: Many children with asthma use the ED as a typical source of healthcare, and are distinguished by need for proximity, poorer caregiver QOL, and historic patterns of care-seeking. Efforts to improve timely access to outpatient care and reinforce the role of PCP-directed asthma management, such as through telemedicine, may reduce preventable morbidity including ED visits.
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Affiliation(s)
- Erin Davis
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Maria Fagnano
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jill S Halterman
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sean M Frey
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Scott J, Khanom A, Straw J, Strickland A, Porter A, Snooks H. Paediatric frequent use of emergency medical services: a systematic review. Emerg Med J 2022; 40:emermed-2021-211701. [PMID: 36600465 DOI: 10.1136/emermed-2021-211701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Frequent use of emergency medical services (EMS) is recognised to be a global phenomenon, although paediatric frequent use is poorly understood. This systematic review aimed to understand how paediatric frequent use of EMS is currently defined, identify factors associated with paediatric frequent use of EMS and determine effectiveness of interventions for paediatric patients who frequently use EMS. METHODS Four electronic databases (Medline, CINAHL, Web of Science and PsycINFO) were searched to September 2022 for primary, peer-reviewed research studies published in English from January 2000. Studies were included that examined frequent use (>1 contact during study period) of EMS or other services with arrival via EMS. Paediatric patients were defined as <18 years of age or otherwise defined by study authors as paediatric/adolescent/children. Data were extracted using a structured proforma, and quality was assessed using the Standard Quality Assessment Criteria for Quantitative Studies but did not influence inclusion decisions. Data were presented using narrative synthesis. RESULTS The search resulted in 4172 unique references, with 12 papers included in the review from 7 countries. Four were EMS studies, and eight Emergency Department with arrival via EMS. All studies used retrospective designs, with no interventional studies identified. Paediatric frequent EMS users were more likely to use services for medical reasons rather than trauma, including respiratory complaints, mental health and seizures, but data on gender and ethnicity were inconclusive and silent on socioeconomic status. There was no consistency in definitions of either a paediatric patient or of frequent use. CONCLUSION The broad range of reasons for frequent use suggests that a single intervention is unlikely to be effective at addressing the causes of frequent use. There is a need for further research to better identify the underlying reasons for frequent EMS use among paediatric patients and to develop interventions in this population.
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Affiliation(s)
- Jason Scott
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | | | - Joanne Straw
- Emergency Operations Centre, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Annette Strickland
- Emergency Operations Centre, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Alison Porter
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
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15
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Parental Childhood Adversity and Pediatric Emergency Department Utilization: A Pilot Study. Pediatr Emerg Care 2022; 38:665-671. [PMID: 36375010 DOI: 10.1097/pec.0000000000002875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Adverse childhood experiences (ACEs) including physical, emotional, or sexual abuse; neglect; and/or exposure to household instability have been associated with adult emergency department utilization, but the impact of parental ACEs on pediatric emergency department (PED) utilization has not been studied. The primary aim was to determine if parental ACEs impact resource utilization as measured by (1) frequency of PED utilization, (2) acuity of PED visits, and (3) 72-hour PED return rates. The secondary aim was to determine if resilience interacts with the impact of parental ACEs on PED utilization. METHODS This study is a cross-sectional survey using previously validated measures of ACEs, resiliency, and social determinants of health screening. Surveys were administered from October 17, 2019, to November 27, 2019, via iPad by research assistants in our institution's PEDs. Survey responses were linked to data abstracted from the electronic health record. Descriptive statistics were used to characterize our study population. Pearson correlation was used to identify correlation between ACEs, social determinants of health, and PED utilization measures. RESULTS A total of 251 parents had complete data. Parental ACEs were positively associated with frequency of PED visits (incidence rate ratio, 1.013). In addition, high levels of parental resilience attenuated the association between parental ACEs and the number of severe acuity visits and were associated with fewer 72-hour return visits (incidence rate ratio, 0.49). CONCLUSIONS Parental ACEs appear to be positively associated with frequency of PED utilization and inversely associated with higher-acuity PED visits and parental resiliency.
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Fishe JN, Heintz H, Owusu-Ansah S, Schmucker K, Riney LC, Semenova O, Garvan G, Browne LR. Prehospital Pediatric Asthma Care during COVID-19: Changes to EMS Treatment Protocols and Downstream Clinical Effects. PREHOSP EMERG CARE 2022; 27:893-899. [PMID: 36260781 PMCID: PMC10164835 DOI: 10.1080/10903127.2022.2137864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic, many emergency medical services (EMS) agencies modified treatment guidelines for clinical care and standard operating procedures. For the prehospital care of pediatric asthma exacerbations, modifications included changes to bronchodilator administration, systemic corticosteroid administration, and introduction of alternative medications. Since timely administration of bronchodilators and systemic corticosteroids has been shown to improve pediatric asthma clinical outcomes, we investigated the association of COVID-19 protocol modifications in the prehospital management of pediatric asthma on hospital admission rates and emergency department (ED) length-of-stay. METHODS This is a multicenter, retrospective, observational cohort study comparing prehospital pediatric asthma patients treated by EMS clinicians from four EMS systems before and after implementation of COVID-19 interim EMS protocol modifications. We included children ages 2-18 years who were treated and transported by ground EMS for respiratory-related prehospital primary complaints, and who also had asthma-related ED discharge diagnoses. Patient data and outcomes were compared from 12 months prior to and 12 months after the implementation of interim COVID-19 prehospital protocol modifications using univariate and multivariable statistics. RESULTS A total of 430 patients met inclusion criteria with a median age of 8 years. There was a slight male predominance (57.9%) and the majority of patients were African American (78.4%). There were twice as many patients treated prior to the COVID-19 protocol modifications (N = 287) compared to after (N = 143). There was a significant decrease in EMS bronchodilator administration from 76% to 59.4% of patients after COVID-19 protocol guidelines were implemented (p < 0.0001). Mixed effects models for hospital admission (to both pediatric inpatient units and pediatric intensive care units) as well as ED length-of-stay did not show any significant effect after the COVID-19 protocol change period (p = 0.18 and p = 0.55, respectively). CONCLUSIONS Despite a decrease in prehospital bronchodilator administration after COVID-19 changes to prehospital pediatric asthma management protocols, hospital admission rates and ED length-of-stay did not significantly increase. However, this finding is tempered by the marked decrease in study patients treated after COVID-19 prehospital protocol modifications. Given the potential for future waves of COVID-19 variants, further studies with larger patient populations are warranted.
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Affiliation(s)
- Jennifer N Fishe
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Hanna Heintz
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sylvia Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kyle Schmucker
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Lauren C Riney
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Olga Semenova
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gerard Garvan
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
| | - Lorin R Browne
- Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Topsakal S, Ekici B. Effect of illuminated musical mobile on sleep quality of children hospitalized in pediatric emergency departments. J Pediatr Nurs 2022; 67:e156-e164. [PMID: 35973878 DOI: 10.1016/j.pedn.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 07/27/2022] [Accepted: 08/06/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study is to evaluate the effect of an illuminated musical mobile on the sleep quality of children hospitalized in a pediatric emergency department. DESIGN AND METHODS In this randomized controlled study, 124 children presenting to a pediatric emergency department who met the inclusion criteria were included in the study. Patients were randomized into two equal groups. In the intervention group, an illuminated musical mobile was used to help facilitate sleep. In the control group, routine sleep routines were continued. Groups were compared according to sleep quality as evaluated by mothers' observations. Evaluation was performed twice (before intervention - 1st day of hospitalization and on the intervention day - 2nd day of hospitalization). RESULTS Average age of children was 1.86 ± 0.78 years. On the intervention day, nighttime sleep duration was longer in the intervention group (p < .0001). Also, the frequency of spontaneous awakening (p < .0001), time to fall asleep after spontaneous awakening (p < .0001) and sleep time problems (p < .0001) were less in the intervention group. CONCLUSıONS: An illuminated musical mobile was used for the first time in the pediatric emergency department and was found to be effective in improving the sleep quality of hospitalized children aged between 1 and 3 years. PRACTICE IMPLICATIONS During hospitalization, children's sleep quality can be increased by using methods and objects suitable for the child's developmental level.
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Affiliation(s)
- Sinem Topsakal
- Istanbul Ministry of Health Marmara University Pendik Training and Research Hospital, Pediatric Emergency Clinic, Istanbul, Turkey
| | - Behice Ekici
- Maltepe University, School of Nursing, Pediatric Nursing Department, Istanbul, Turkey.
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18
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Hall JE, Pham PK, Liberman DB. Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency. Pediatr Emerg Care 2022; 38:e1620-e1625. [PMID: 36173434 DOI: 10.1097/pec.0000000000002615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization. METHODS A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization. RESULTS In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration. CONCLUSIONS Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.
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Walsh PS, Lipshaw MJ. Diurnal Variation in Frequency and Severity of Croup in the Emergency Department. Hosp Pediatr 2022; 12:e2022006682. [PMID: 36130916 DOI: 10.1542/hpeds.2022-006682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emergency department (ED) presentation for croup is thought to occur more often at night, but evidence for its diurnal variation is sparse. Our objectives were to describe the diurnal patterns of ED presentation in children with croup and to determine whether time of arrival associated with severe clinical outcomes. METHODS We conducted a retrospective cohort study using the Pediatric Health Information System. We included children 3 months to 11 years of age with an ED encounter for croup from 2016 through 2020. We quantified ED encounters by arrival hour and used generalized linear mixed-effects models to determine association between arrival time and racemic epinephrine use, hospitalization, intensive care unit (ICU) admission, and revisits. RESULTS There was considerable diurnal variation in ED visits for croup. A total of 126 186 children (60.1%) presented to the ED at night (between 8 pm and 8 am), and 83 763 children presented during the day (39.9%). Peak arrival time was 12:00 am (14 189 encounters) and the nadir was at 2:00 pm (5231 encounters). Children presenting during overnight hours had increased odds of the use of racemic epinephrine (odds ratio [OR] 1.33; 95% confidence interval [95% CI], 1.30-1.36), but reduced odds of hospitalization (OR 0.76; 95% CI, 0.73-0.78), ICU admission (OR 0.61; 95% CI, 0.58-0.68), and 3 day ED revisits (OR 0.86; 95% CI, 0.83-0.90). CONCLUSIONS Children with croup present to the ED more commonly at night. Children presenting to the ED with croup at night have greater odds of being treated with racemic epinephrine, but reduced odds of hospitalization, ICU admission, and return visits.
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Affiliation(s)
- Patrick S Walsh
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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20
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Lipshaw MJ, Walsh PS. Transient synovitis of the hip: Current practice and risk of misdiagnosis. Am J Emerg Med 2022; 61:1-6. [PMID: 35994972 DOI: 10.1016/j.ajem.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Transient synovitis (TS) is a common and benign cause of hip pain in children, but must be distinguished from more serious entities such as septic arthritis, osteomyelitis, and pyomyositis. Our objectives were to determine the risk of missed bacterial musculoskeletal infection and rates of diagnostic testing in children diagnosed with TS. METHODS We performed a cohort study using the Pediatric Heath Information System of children 1-10 years diagnosed with TS in the ED. We determined rates of missed bacterial musculoskeletal infection (defined as a new diagnosis of septic arthritis, osteomyelitis, or pyomyositis within 14 days of initial ED visit). We described the initial diagnostic evaluation and ED management of children diagnosed with TS and variability between sites. RESULTS We analyzed 6419 encounters from 37 hospitals. 62 (1.0%, 95%CI: 0.7-1.2%) children were diagnosed with a missed bacterial musculoskeletal infection. Children with missed infection were younger than those without (median age 2.6 vs. 4.6 years, p < 0.01). Serum laboratory testing was performed in 76% of encounters with minimal variation across sites. There was significant variation in the rates of hip ultrasound by site (2 to 92%), which has increased in use over time (from 42% in 2016 to 62% in 2021). CONCLUSION In this large observational study, missed bacterial musculoskeletal infection in children diagnosed with TS was rare but more common in younger children. The optimal combination of bloodwork and radiographic testing, especially ultrasound, to distinguish TS from more serious disease remains unclear.
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Affiliation(s)
- Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Patrick S Walsh
- Section of Emergency Medicine, Children's Hospital of Wisconsin, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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21
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Ramgopal S, Varma S, Victor TW, McCarthy DM, Rising KL. Pediatric Return Visits to the Emergency Department: The Time to Return Curve. Pediatr Emerg Care 2022; 38:e1454-e1461. [PMID: 35727757 DOI: 10.1097/pec.0000000000002790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although 72-hour return visits are a frequently reported metric for pediatric patients discharged from the emergency department (ED), the basis for this metric is not established. Our objective was to statistically derive a cutoff time point for the characterization of pediatric return visits. METHODS We performed a retrospective cohort study using data of patients discharged from any of 44 pediatric EDs. We selected the first encounter per patient from January 1 to December 31, 2019, as the index encounter and included the first return visit within 30 days. We constructed a cumulative hazard curve to characterize the timing of return visits and constructed a multivariable adaptive regression spline model to identify a hinge point in return visit presentations. We identified the association between admission for early return visits and admission for late return visits using generalized linear mixed modeling. RESULTS Of 1,986,778 index ED discharges, 193,605 (9.7%) ED return visits were included. A double-exponential decay model demonstrated superior fit compared with a single exponential model ( P < 0.0001). Multivariable adaptive regression spline modeling identified a hinge at 7 days. When comparing proportions of return visits leading to hospitalization between early (23.8%) and late (15.1%) return visits, early visits (≤7 days) had higher adjusted odds of hospital admission (adjusted odds ratio, 1.73; 95% confidence interval, 1.69-1.77) relative to late return visits (>7 days). Findings were similar in sensitivity analyses within age subgroups, Census region, and in which the diagnosis (using the Diagnosis and Grouping System) was the same between the index and return visit. Among return visits that occurred within 7 days of the index visit, 46.3% had the same diagnosis grouping in both visits. CONCLUSIONS An empirically derived 7-day cutoff may be more appropriate for characterization of pediatric return visits to the ED. Encounters after this period had lower adjusted odds of admission.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Selina Varma
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Timothy W Victor
- Graduate School of Education, University of Pennsylvania, Philadelphia, PA
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Westphaln KK, Fry-Bowers EK, Birchfield JW, Lee E, Ronis SD. Examining the Relationship of Family Social Capital and Use of Pediatric Primary Health Care Services in the 2016-19 National Survey of Children's Health. J Pediatr Health Care 2022; 36:347-357. [PMID: 34996680 DOI: 10.1016/j.pedhc.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This study examined the relationship of family social capital (FSC) and pediatric primary health care services (PHCU) among young children aged 0-5 years in the United States. FSC involves the interrelated contexts of child health and family characteristics. Understanding how this impacts PHCU may reveal important considerations for supporting access and use of essential health care services. METHOD Using data from the 2016-19 National Survey of Children's Health (weighted N = 21,496,634), we conducted descriptive statistics and logistic regression to ascertain the relationship between FSC and PHCU. RESULTS Statistically significant contributions included FSC (odds ratio [OR] = 1.2; confidence interval [CI] = 1.08-1.40), high school (OR = 0.49; CI = 2.65-5.39), and some college (OR = 0.72; CI = 0.62-0.85) DISCUSSION: Findings support that FSC and parent academic achievement impact PHCU. Interventions that foster family connection and parent adult health literacy may enhance PHCU.
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Affiliation(s)
- Kristi K Westphaln
- Assistant Professor, School of Nursing, University of California Los Angeles, Los Angeles, CA; University Hospitals Center for Child Health and Policy, and Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Eileen K Fry-Bowers
- Professor and Associate Provost, Hahn School of Nursing and Health Science, University of San Diego, San Diego, CA
| | - Jesse W Birchfield
- Doctoral Student, Department of Biostatistics, University of California Los Angeles, Los Angeles, CA
| | - Eunice Lee
- Lecturer, Jack, Joseph, and Morton Mandel School of Applied Social Science, Case Western Reserve University, Cleveland, OH
| | - Sarah D Ronis
- Director, University Hospitals Center for Child Health and Policy, and Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
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Wozney L, Curran J, Archambault P, Cassidy C, Jabbour M, Mackay R, Newton A, Plint AC, Somerville M. Electronic Discharge Communication Tools Used in Pediatric Emergency Departments: Systematic Review. JMIR Pediatr Parent 2022; 5:e36878. [PMID: 35608929 PMCID: PMC9270703 DOI: 10.2196/36878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Electronic discharge communication tools (EDCTs) are increasingly common in pediatric emergency departments (EDs). These tools have been shown to improve patient-centered communication, support postdischarge care at home, and reduce unnecessary return visits to the ED. OBJECTIVE This study aimed to map and assess the evidence base for EDCTs used in pediatric EDs according to their functionalities, intended purpose, implementation context features, and outcomes. METHODS A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) procedures for identification, screening, and eligibility. A total of 7 databases (EBSCO, MEDLINE, CINAHL, PsycINFO, EMBASE Scopus, and Web of Science) were searched for studies published between 1989 and 2021. Studies evaluating discharge communication-related outcomes using electronic tools (eg, text messages, videos, and kiosks) in pediatric EDs were included. In all, 2 researchers independently assessed the eligibility. Extracted data related to study identification, methodology, settings and demographics, intervention features, outcome implementation features, and practice, policy, and research implications. The Mixed Method Appraisal Tool was used to assess methodological quality. The synthesis of results involved structured tabulation, vote counting, recoding into common metrics, inductive thematic analysis, descriptive statistics, and heat mapping. RESULTS In total, 231 full-text articles and abstracts were screened for review inclusion with 49 reports (representing 55 unique tools) included. In all, 70% (26/37) of the studies met at least three of five Mixed Method Appraisal Tool criteria. The most common EDCTs were videos, text messages, kiosks, and phone calls. The time required to use the tools ranged from 120 seconds to 80 minutes. The EDCTs were evaluated for numerous presenting conditions (eg, asthma, fracture, head injury, fever, and otitis media) that required a range of at-home care needs after the ED visit. The most frequently measured outcomes were knowledge acquisition, caregiver and patient beliefs and attitudes, and health service use. Unvalidated self-report measures were typically used for measurement. Health care provider satisfaction or system-level impacts were infrequently measured in studies. The directionality of primary outcomes pointed to positive effects for the primary measure (44/55, 80%) or no significant difference (10/55, 18%). Only one study reported negative findings, with an increase in return visits to the ED after receiving the intervention compared with the control group. CONCLUSIONS This review is the first to map the broad literature of EDCTs used in pediatric EDs. The findings suggest a promising evidence base, demonstrating that EDCTs have been successfully integrated across clinical contexts and deployed via diverse technological modalities. Although caregiver and patient satisfaction with EDCTs is high, future research should use robust trials using consistent measures of communication quality, clinician experience, cost-effectiveness, and health service use to accumulate evidence regarding these outcomes. TRIAL REGISTRATION PROSPERO CRD42020157500; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=157500.
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Affiliation(s)
- Lori Wozney
- Mental Health and Addictions, Nova Scotia Health, Dartmouth, NS, Canada
| | - Janet Curran
- IWK Health, Strengthening Transitions in Care Lab, Halifax, NS, Canada
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Patrick Archambault
- Département de médecine d'urgence, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Levis, QC, Canada
| | | | - Mona Jabbour
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Rebecca Mackay
- IWK Health, Strengthening Transitions in Care Lab, Halifax, NS, Canada
| | - Amanda Newton
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Amy C Plint
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mari Somerville
- IWK Health, Strengthening Transitions in Care Lab, Halifax, NS, Canada
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Rosychuk RJ, Chen AA, McRae A, McLane P, Ospina MB, Hu XIJ. Age-varying effects of repeated emergency department presentations for children in Canada. J Health Serv Res Policy 2022; 27:278-286. [PMID: 35521743 PMCID: PMC9548929 DOI: 10.1177/13558196221094248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Rhonda J Rosychuk
- Department of Pediatrics, 3158University of Alberta, Edmonton, AB, Canada
| | - Anqi A Chen
- Department of Statistics and Actuarial Science, 1763Simon Fraser University, Burnaby, BC, Canada
| | - Andrew McRae
- Department of Emergency Medicine, 2129University of Calgary, Calgary, AB, Canada
| | - Patrick McLane
- Emergency Strategic Clinical Network, 3146Alberta Health Services, Edmonton, Canada
| | - Maria B Ospina
- Department of Pediatrics, 3158University of Alberta, Edmonton, AB, Canada
| | - X Iaoqiong Joan Hu
- Department of Statistics and Actuarial Science, 1763Simon Fraser University, Burnaby, BC, Canada
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25
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Walsh PS, Gray JM, Ramgopal S, Lipshaw MJ. Risk of malignancy following emergency department Bell's palsy diagnosis in children. Am J Emerg Med 2022; 53:63-67. [PMID: 34992025 DOI: 10.1016/j.ajem.2021.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/14/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To quantify the risk of malignancy following the emergency department (ED) diagnosis of Bell's Palsy (BP) using a large retrospective cohort. STUDY DESIGN We performed a cohort study using the Pediatric Health Information System database. We included all children (6 months - 17 years) from 2011 to 2020 with an ED diagnosis of BP. We excluded children with previous neurologic chronic condition or malignancy diagnosed during or prior to the index visit. Our primary outcome was diagnosis of malignancy within 60 days following the index ED visit. We compared clinical characteristics between children with and without new-onset malignancy. RESULTS Of 12,272 encounters for BP, 41 had a new oncologic diagnosis within 60 days (0.33%, 95% confidence interval [CI]: 0.25-0.45%). Median time to oncologic diagnosis was 22 days. Primary CNS malignancy (59%) and leukemia (17.1%) were the most common diagnoses. Younger children had a higher incidence of new oncologic diagnosis compared with older children. Incidences were 0.68% (95% CI 0.36-1.3%), 0.70% (95% CI 0.38-1.3%), 0.26% (95% CI 0.15-0.47%), and 0.21% (95% CI 0.12-0.37%) for children aged <2 years, 2-5 years, 6-11 years, and 12-17 years respectively. CONCLUSIONS We found a small but potentially clinically significant rate of new-onset oncologic diagnosis within 60 days after BP diagnosis in the ED, especially in children younger than 5 years. Further studies of the diagnostic utility of laboratory testing or neuroimaging and the risk of empiric steroids in children with BP are needed.
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Affiliation(s)
- Patrick S Walsh
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America.
| | - James M Gray
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Sriram Ramgopal
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States of America
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
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Rosychuk RJ, Chen A, McRae A, McLane P, Ospina MB, Stang AS. Characteristics of Pediatric Frequent Users of Emergency Departments in Alberta and Ontario. Pediatr Emerg Care 2022; 38:108-114. [PMID: 34772876 DOI: 10.1097/pec.0000000000002569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Emergency department (ED) volumes have drawn attention to frequent users but less attention has been paid to children. This study examined sociodemographic and ED presentation characteristics of pediatric high-system ED users (HSUs) in 2 provinces in Canada. METHODS Cohorts of HSUs were created from the National Ambulatory Care Reporting System in 2015/2016 for children with the top 10% of ED presentations. Controls were random samples of non-HSU patients. Factors were explored in multivariable logistic regression models. RESULTS There were 151,497 HSUs (51.7% girls, average age, 6.4 years) and 591,545 controls (53.1% girls; average age, 7.4 years). High-system ED users were more likely to be younger (adjusted odds ratio [aOR], 0.89 per 5 years; 95% confidence interval [CI], 0.88-0.89), live in less populated areas (aOR, 1.85; 95% CI, 1.82-1.88), and from lowest income neighborhoods (aOR, 1.51; 95% CI, 1.48-1.54) than controls. High-system ED users had higher proportions of presentations for pediatric complex chronic (aOR, 1.25 per 0.25 increase; 95% CI, 1.21-1.29), respiratory (aOR, 1.14 per 0.25; 95% CI, 1.12-1.15), and mental health (aOR, 1.14 per 0.25; 95% CI, 1.13-1.16) conditions than controls. CONCLUSIONS Complex factors underlie pediatric health care utilization decisions. Findings identified conditions to target in interventions to improve health care access and utilization. Future work should engage children and families to design interventions.
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Murray A, Fein J, Beulah B, Mollen C. Examination of Caregiver Social Factors and Its Influence on Low-Acuity Pediatric Emergency Department Utilization. Pediatr Emerg Care 2022; 38:e611-e617. [PMID: 33848096 DOI: 10.1097/pec.0000000000002426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Social factors, such as adverse childhood experiences (ACEs), often influence health care utilization. Our study explores the association between caregiver social factors and low-acuity pediatric emergency department (ED) utilization, with the hypothesis that caregivers with high ACE exposure may use ED services more frequently for low-acuity complaints. METHODS In this case-control study, we performed surveys of caregivers with children aged 1 to 12 years registered for care in our pediatric ED. We defined high utilizers (cases) as those children with ≥3 low-acuity visits in the previous year and low utilizers (controls) as having no prior low-acuity visits, exclusive of the current visit. We compared the proportion of high ACE exposure (≥4 ACEs) between both groups. RESULTS We enrolled 114 cases and 134 controls. We found no association between number of ACEs and odds of being a case or control (ED utilization). Demographics were significantly different between the 2 groups (ie, caregiver age, race, education, and household income); caregiver ACE exposure was high in both groups (20.2% cases vs 29.1% controls with [≥4 ACEs]). CONCLUSIONS Although we did not find an association between caregiver ACEs and frequent low-acuity pediatric ED utilization, our data shed light on the overall prevalence of caregiver ACEs in families that seek care in our pediatric ED, even for the first time. Our findings emphasize the risk of conscious bias that can lead to inaccuracy: assuming that it is only high utilizers who experience social stressors. Future work should explore the contribution of structural inequities that influence caretakers' decisions to seek care for their children for low-acuity complaints, and consider types of interventions that could address and mitigate these inequities.
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Affiliation(s)
| | | | - Brianna Beulah
- Center for Violence Prevention, Children's Hospital of Philadelphia, Philadelphia, PA
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Michelson KA, Cushing AM, Bucholz EM. Association of County-Level Availability of Pediatricians With Emergency Department Visits. Pediatr Emerg Care 2022; 38:e953-e957. [PMID: 34282091 PMCID: PMC8770659 DOI: 10.1097/pec.0000000000002502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The relationship between pediatrician availability and emergency department (ED) attendance is uncertain. We determined whether children in counties with more pediatricians had fewer ED visits. METHODS We conducted a cross-sectional study of all ED visits among children younger than 18 years from 6 states. We obtained ED visit incidences by county and assessed the relationship to pediatrician density (pediatricians per 1000 children). Possible confounders included state, presence of an urgent care facility in the county, urban-rural status, and quartile of county-level characteristics: English-speaking, Internet access, White race, socioeconomic status, and public insurance. We estimated county-level changes in incidence by pediatrician density adjusting for state and separately for all possible confounders. RESULTS Each additional pediatrician per 1000 children was associated with a 13.7% (95% confidence interval, -19.6% to -7.5%) decrease in ED visits in the state-adjusted model. In the full model, there was no association (-1.4%, 95% confidence interval, -7.2% to 4.8%). The presence of an urgent care, higher socioeconomic status score, urban status, and higher proportions of White race and nonpublic insurance were each associated with decreased ED visit rates. CONCLUSIONS Pediatrician density is not associated with decreased ED visits after adjusting for other county demographic factors. Increasing an area's availability of pediatricians may not affect ED attendance.
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Affiliation(s)
| | - Anna M Cushing
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Emily M Bucholz
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA
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Pulcini CD, Coller RJ, Macy ML, Alpern E, Harris D, Rodean J, Hall M, Chung PJ, Berry JG. Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions. Pediatr Emerg Care 2022; 38:e856-e862. [PMID: 34009894 DOI: 10.1097/pec.0000000000002437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC. METHODS A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit. RESULTS Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5]). CONCLUSIONS Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings.
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Affiliation(s)
- Christian D Pulcini
- From the Department of Surgery and Pediatrics, University of Vermont Medical Center and Children's Hospital, University of Vermont Larner College of Medicine, Burlington, VT
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Elizabeth Alpern
- Division of Emergency Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | | | | | | | - Paul J Chung
- Health Systems Science, Kaiser Permanente School of Medicine, Departments of Pediatrics and Health Policy & Management, UCLA RAND Health, RAND Corporation, Los Angeles, CA
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Sojar S, Gjelsvik A, Tsao HS, Amanullah S. Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment. Pediatr Emerg Care 2022; 38:e569-e574. [PMID: 33635045 DOI: 10.1097/pec.0000000000002319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States. METHODS The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health. RESULTS Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits. CONCLUSIONS Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.
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31
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Vrijlandt SEW, Nieboer D, Zachariasse JM, Oostenbrink R. Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: A large observational study using electronic health record data. PLoS One 2022; 17:e0262432. [PMID: 35085300 PMCID: PMC8794145 DOI: 10.1371/journal.pone.0262432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/22/2021] [Indexed: 11/19/2022] Open
Abstract
Background Among pediatric emergency department (ED) visits, a subgroup of children repeatedly visits the ED, making them frequent visitors (FVs). The aim of this study is to get insight into the group of pediatric ED FVs and to determine risk factors associated with a revisit. Methods and findings Data of all children aged 0–18 years visiting the ED of a university hospital in the Netherlands between 2017 and 2020 were included in this observational study based on routine data extraction. Children with 4 or more ED visits within 365 days were classified as FVs. Descriptive analysis of the study cohort at patient- and visit-level were performed. Risk factors for a recurrent ED visit were determined using a Prentice Williams and Peterson gap time cox-based model. Our study population of 10,209 children with 16,397 ED visits contained 500 FVs (4.9%) accounting for 3,481 visits (21.2%). At patient-level, FVs were younger and more often suffered from chronic diseases (CDs). At visit-level, frequent visits were more often initiated by self-referral and were more often related to medical problems (compared to trauma’s). Overall, FVs presented at the ED more often because of an infection (41.3%) compared to non-FVs (27.4%), either associated or not with the body system affected by the CD. We identified the presence of a comorbidity (non-complex CD HR 1.66; 1.52–1.81 and complex CD HR 2.00; 1.84–2.16) as determinants with the highest hazard for a return visit. Conclusion Pediatric ED FVs are a small group of children but account for a large amount of the total ED visits. FVs are younger patients, suffering from (complex) comorbidities and present more often with infectious conditions compared to non-FVs. Healthcare pathways, including safety-netting strategies for acute manifestations from their comorbidity, or for infectious conditions in general may contribute to support parents and redirect some patients from the ED.
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Affiliation(s)
- Sanne E. W. Vrijlandt
- Department of General Pediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Daan Nieboer
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Joany M. Zachariasse
- Department of General Pediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Pediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- * E-mail:
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Cohen JS, Berkowitz D, Nosker L, Shaukat H, Kim D, Koutroulis I, Breslin KA. Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits. Pediatr Emerg Care 2022; 38:e417-e421. [PMID: 33273428 DOI: 10.1097/pec.0000000000002312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pediatric patients account for a disproportionate number of low-acuity emergency department (ED) visits. The aim of this study is to describe pediatric patient and visit characteristics for high-frequency users for low-acuity visits. METHODS This was a retrospective cohort study of children presenting to a tertiary care pediatric ED and an affiliated community ED, over a 2-year period, with at least 10 low-acuity visits. Twenty patients with the highest number of visits were classified as "superusers." We analyzed patient data from the larger sample of high-frequency users and visit specific data from superuser visits. IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL) was used to perform descriptive statistics and to summarize demographic and visit specific variables. RESULTS We identified 181 high-frequency users with a mean number of visits of 14.3 ± 4.3 and a subpopulation of 20 superusers accounting for 434 visits. The majority of high-frequency users (89%) identified as African American and had public insurance (96.1%). Many patients received primary care affiliated with the home institution. In the first year of the study, 50.3% of high-frequency users were infants younger than 1 year at the index visit and 47.4% of superusers were infants at the index visit.Superuser visits were evenly distributed among seasons and the majority of visits occurred during the weekdays (70.7%). The majority of visits were for medical complaints (86.6%) and almost half (47.6%) resulted in some testing (24.9%) or treatment (30.6%); however, only 1.4% resulted in hospital admission. CONCLUSIONS In our sample, most high-frequency low-acuity ED patients were infants, African American and have public insurance. Many are seen during clinic hours and are paneled at affiliated clinics. Among superusers, the majority of the visits did not require any testing, intervention, or treatment.
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Affiliation(s)
| | | | - Lois Nosker
- From the Division of Emergency Medicine, Children's National Health System
| | | | - Dana Kim
- From the Division of Emergency Medicine, Children's National Health System
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Zhou AZ, Marin JR, Hickey RW, Lam SK, Ramgopal S. Serious diagnoses at revisits in children discharged from the emergency department with back pain. Acad Emerg Med 2021; 28:1299-1307. [PMID: 34245643 DOI: 10.1111/acem.14336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Back pain is often benign but can be a harbinger for serious pathology. Little is known about the outcome in children with back pain but no serious diagnoses detected at the initial visit. We sought to estimate the rate of serious diagnoses at revisits among children initially discharged from the emergency department (ED) with back pain. METHODS We performed a multicenter retrospective cohort study of patients from 45 pediatric hospitals in the Pediatric Health Information System database from October 1, 2015, to March 31, 2019. We included patients discharged from the ED with a principal diagnosis of back pain and excluded patients with trauma and concurrent or previously known serious diagnoses. We identified the rates and types of serious diagnoses made within 30 days of the index visit. We examined the rates of diagnostic tests at the index visit in patients with and without serious diagnoses. RESULTS Of the 25,130 patients with back pain, 88 (0.4%, 95% confidence interval = 0.3% to 0.4%) had serious pathology diagnosed within 30 days. The most common diagnoses were anatomic (40%) and nonneurologic (39%) categories such as vertebral fracture and nephrolithiasis; infectious (19%) and neoplastic etiologies (3%) were less common. Diagnoses requiring acute interventions such as cauda equina syndrome (n = 2) and intraspinal abscess (n = 3) were rare. Patients with serious diagnoses at revisits underwent more blood tests and back ultrasound at the index visit compared to patients without serious diagnoses. CONCLUSIONS In pediatric patients discharged from the ED with a diagnosis of back pain and no serious or trauma diagnoses, there is a low rate of serious pathology on revisits. Of the serious diagnoses identified, high-acuity diseases were rare. For the subset of patients with clinical suspicion for serious pathology but none identified at the index visit, this represents an opportunity for further research to optimize their management.
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Affiliation(s)
- Amy Z. Zhou
- Division of Emergency Medicine Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine Department of Pediatrics UPMC Children’s Hospital of PittsburghUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine Department of Pediatrics UPMC Children’s Hospital of PittsburghUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Sandi K. Lam
- Department of Neurosurgery Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Sriram Ramgopal
- Division of Emergency Medicine Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
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34
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Greenfield G, Okoli O, Quezada-Yamamoto H, Blair M, Saxena S, Majeed A, Hayhoe B. Characteristics of frequently attending children in hospital emergency departments: a systematic review. BMJ Open 2021; 11:e051409. [PMID: 34663662 PMCID: PMC8523960 DOI: 10.1136/bmjopen-2021-051409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To summarise the literature on frequent attendances to hospital emergency departments (EDs) and describe sociodemographic and clinical characteristics of children who attend EDs frequently. SETTING Hospital EDs. PARTICIPANTS Children <21 years, attending hospital EDs frequently. PRIMARY OUTCOME MEASURES Outcomes measures were defined separately in each study, and were predominantly the number of ED attendances per year. RESULTS We included 21 studies representing 6 513 627 children. Between 0.3% and 75% of all paediatric ED users were frequent users. Most studies defined four or more visits per year as a 'frequent ED' usage. Children who were frequent ED users were more likely to be less than 5 years old. In the USA, patients with public insurance were more likely to be frequent attenders. Frequent ED users more likely to be frequent users of primary care and have long-term conditions; the most common diagnoses were infections and gastroenteritis. CONCLUSIONS The review included a wide range of information across various health systems, however, children who were frequent ED users have some universal characteristics in common. Policies to reduce frequent attendance might usefully focus on preschool children and supporting primary care in responding to primary care oriented conditions.
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Affiliation(s)
- Geva Greenfield
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Olivia Okoli
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Harumi Quezada-Yamamoto
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Mitch Blair
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Benedict Hayhoe
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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35
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Fang A, Hersh M, Birgisson N, Saynina O, Wang NE. "Could we have predicted this?" The association of a future mental health need in young people with a non-specific complaint and frequent emergency department visits. J Am Coll Emerg Physicians Open 2021; 2:e12556. [PMID: 34632448 PMCID: PMC8495458 DOI: 10.1002/emp2.12556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Mental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non-specific condition and emergency department (ED) revisits have increased mental health needs. METHODS Retrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010-2014) of young people (11-24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of "Symptoms, signs, and ill-defined conditions" (Non-Specific); "Diseases of the respiratory system" (Respiratory) and "Unintentional injury" (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit. RESULTS Patients in the Non-Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17-1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non-Specific index visit and 1, 2, and 3 or more revisits with non-specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29-1.47; OR 1.70; 95% CI 1.46-1.98; OR 2.20; 95% CI 1.70-2.87, respectively.). CONCLUSIONS Young people who go to the ED for non-specific conditions and revisits may benefit from targeted ED mental health screening.
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Affiliation(s)
- Andrea Fang
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Melissa Hersh
- Department of Emergency MedicineValley Children's HospitalMaderaCaliforniaUSA
| | - Natalia Birgisson
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Olga Saynina
- Stanford Center for PolicyOutcomes and PreventionStanfordCaliforniaUSA
| | - Nancy E Wang
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
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Patel NH, Hassoun A, Chao JH. The Practice of Obtaining a Chest Radiograph in Pediatric Patients Presenting With Their First Episode of Wheezing: A Survey of Resident Physicians. Clin Pediatr (Phila) 2021; 60:465-473. [PMID: 34486411 DOI: 10.1177/00099228211044296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A chest radiograph (CXR) is not routinely indicated in children presenting with their first episode of wheezing; however, it continues to be overused. A survey was distributed electronically to determine what trainees are taught and their current practice of obtaining a CXR in children presenting with their first episode of wheezing and the factors that influence this practice. Of the 1513 trainees who completed surveys, 35.3% (535/1513) reported that they were taught that pediatric patients presenting with their first episode of wheezing should be evaluated with a CXR. In all, 22.01% (333/1513) indicated that they would always obtain a CXR in these patients, and 13.75% (208/1513) would always obtain a CXR under a certain age (4 weeks to 12 years, median of 2 years). Our study identifies a target audience that would benefit from education to decrease the overuse of CXRs in children.
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Affiliation(s)
| | - Ameer Hassoun
- New York Presbyterian-Queens Hospital, Flushing, NY, USA
| | - Jennifer H Chao
- SUNY Downstate Medical Center/Kings County Hospital Center, Brooklyn, NY, USA
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Goodman WB, Dodge KA, Bai Y, Murphy RA, O’Donnell K. Effect of a Universal Postpartum Nurse Home Visiting Program on Child Maltreatment and Emergency Medical Care at 5 Years of Age: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116024. [PMID: 34232300 PMCID: PMC8264647 DOI: 10.1001/jamanetworkopen.2021.16024] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE The Family Connects (FC) program, a community-wide nurse home visiting program for newborns, has been shown to provide benefits for children and families through the first 2 years of life. Potential longer-term outcomes for child well-being remain unknown. OBJECTIVE To determine the effect of randomization to FC on child maltreatment investigations and emergency medical care through 5 years of age. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, families of all 4777 resident births in Durham County, North Carolina, from July 1, 2009, to December 31, 2010, were randomly assigned to receive the FC program or treatment as usual. Impact evaluation was on an intent-to-treat basis and focused on a subsample of 549 families randomly selected from the full population and included review of hospital and Child Protective Services (CPS) administrative records. Statistical analysis was conducted from November 6, 2020, to April 25, 2021. INTERVENTIONS The FC programs includes 1 to 3 nurse home visits beginning at the infant age of 3 weeks designed to identify family-specific needs, deliver education and intervention, and connect families with community resources matched to their needs. Ongoing program engagement with service professionals and an electronic resource directory facilitate effective family connections to the community. MAIN OUTCOMES AND MEASURES Two primary trial outcomes were CPS-recorded child maltreatment investigations and emergency medical care use based on hospital records. RESULTS Of the 4777 randomized families, 2327 were allocated to the intervention, and 2440 were allocated to services as usual. Among the children in the full study population, 2380 (49.8%) were female, 2397 (50.2%) were male, and 3359 (70.3%) were from racial/ethnic minority groups; of the 531 children included in the impact evaluation follow-up, 284 (53.5%) were female, 247 (46.5%) were male, and 390 (73.4%) were from racial/ethnic minority groups. Negative binomial models indicated that families assigned to FC had 39% fewer CPS investigations for suspected child maltreatment through 5 years of age (95% CI, -0.80 to 0.06; 90% CI, -0.73 to -0.01; control = 44 total investigations per 100 children and intervention = 27 total investigations per 100 children); intervention effects did not differ across subgroups. Families assigned to FC also had 33% less total child emergency medical care use (95% CI, -0.59 to -0.14; 90% CI, -0.55 to -0.18; control = 338 visits and overnight hospital stays per 100 children and intervention = 227 visits and overnight hospital stays per 100 children). Positive effects held across birth risk, child health insurance, child sex, single-parent status, and racial/ethnic groups. Effects were larger for nonminority families compared with minority families. CONCLUSIONS AND RELEVANCE The findings of this randomized clinical trial suggest that, when implemented with high quality and broad reach, a brief postpartum nurse home visiting program can reduce population rates of child maltreatment and emergency medical care use in early childhood. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01406184.
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Affiliation(s)
| | - Kenneth A. Dodge
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Yu Bai
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Robert A. Murphy
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Karen O’Donnell
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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Masonbrink AR, Hunt JA, Bhandal A, Randell KA, Mermelstein S, Wells S, Miller MK. Self-reported and Documented Substance Use Among Adolescents in the Pediatric Hospital. Pediatrics 2021; 147:e2020031468. [PMID: 33941583 PMCID: PMC8168602 DOI: 10.1542/peds.2020-031468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adolescent substance use is associated with numerous adverse health outcomes. A hospitalization represents an opportunity to identify and address substance use. We sought to describe self-reported and documented substance use among hospitalized adolescents. METHODS We conducted a cross-sectional survey of adolescents aged 14 to 18 years old admitted to two pediatric hospitals between August 2019 and March 2020. Using previously validated questions, we assessed the proportion of adolescents reporting ever, monthly, and weekly use of alcohol, marijuana, tobacco, electronic cigarettes, and other illicit drugs and nonmedical use of prescription medications. We reviewed medical records for substance use documentation. RESULTS Among 306 respondents, 57% were older (16-18 years old), 53% were female, and 55% were of non-Hispanic white race and ethnicity. The most frequently reported substances ever used were alcohol (39%), marijuana (33%), and electronic cigarettes (31%); 104 (34%) respondents reported ever use of >1 substance. Compared with younger adolescents, those aged 16 to 18 years were more likely to report ever use of alcohol (29% vs 46%; P = .002), marijuana (22% vs 41%; P < .001), and ≥2 drugs (26% vs 40%; P = .009). A positive substance use history was rarely documented (11% of records reviewed), and concordance between documented and self-reported substance use was also rare. CONCLUSIONS In this study of hospitalized adolescents, the most commonly reported substances used were alcohol, marijuana, and electronic cigarettes. Positive substance use documentation was rare and often discordant with self-reported substance use. Efforts to improve systematic screening for substance use and interventions for prevention and cessation in hospitalized adolescents are critically needed.
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Affiliation(s)
- Abbey R Masonbrink
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri;
- School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Jane Alyce Hunt
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Avleen Bhandal
- School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Kimberly A Randell
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Sarah Mermelstein
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Sarah Wells
- School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Melissa K Miller
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City, Missouri; and
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Wallace JS, Mannix RC. Racial Disparities in Diagnosis of Concussion and Minor Head Trauma and Mechanism of Injury in Pediatric Patients Visiting the Emergency Department. J Pediatr 2021; 233:249-254.e1. [PMID: 33524386 DOI: 10.1016/j.jpeds.2021.01.057] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine if racial/ethnic differences exist in the diagnosis and mechanism of injury among children and adolescents visiting the emergency department (ED) for concussion and minor head trauma (MHT). STUDY DESIGN A retrospective, cross-sectional study of patient (age ≤19 years) visits to the ED for concussion between 2010-2015, using the National Hospital Ambulatory Medical Care Survey, was completed. The primary study exposure was race/ethnicity. Outcome measures included ED visits that resulted in a concussion/MHT diagnosis and mechanism of injury. Mechanism categories included sport, motor vehicle collision, fall, assault, and other mechanism. A multivariable logistic regression and multinomial logistic regression were conducted to assess relationships between race/ethnicity and outcomes. Findings were weighted to reflect population estimates. RESULTS In total, 1263 child/adolescent visits for concussion/MHT were identified, representing an estimated 6.6 million child/adolescent visits nationwide. Compared with non-Hispanic White pediatric patients, non-Hispanic Black patients were least likely to have an ED visit for a concussion/MHT (P < .001; OR, 0.66; 95% CI, 0.52-0.83) The odds of non-Hispanic Black children/adolescents (OR, 3.80; 95% CI, 1.68-8.55) and children/adolescents of other race/ethnicity (OR, 4.93; 95% CI, 1.09-22.23) sustaining a concussion/MHT resulting from assault vs sport was higher. CONCLUSIONS Amid the emerging focus on sport-related concussion, these ethnic/racial differences in ED diagnosis of concussion/MHT demonstrate sociodemographic differences that warrant further attention. Assault may be a more common mechanism of concussion among children/adolescents of a racial minority.
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Affiliation(s)
- Jessica S Wallace
- Department of Epidemiology, Harvard T.H Chan School of Public Health, Boston, MA; Department of Health Science, University of Alabama, Tuscaloosa, AL.
| | - Rebekah C Mannix
- Departments of Pediatrics & Emergency Medicine, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Rintaari KM, Kimani RW, Musembi HM, Gatimu SM. Characteristics and outcomes of patients with an unscheduled return visit within 72 hours to the Paediatric Emergency Centre at a Private Tertiary Referral Hospital in Kenya. Afr J Emerg Med 2021; 11:242-247. [PMID: 33859926 PMCID: PMC8027518 DOI: 10.1016/j.afjem.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 01/28/2021] [Accepted: 03/07/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Patients’ unscheduled return visits (URVs) to the paediatric emergency Centre (PEC) contribute to overcrowding and affect health service delivery and overall quality of care. This study assessed the characteristics and outcomes of paediatric patients with URVs (within 72 hours) to the PEC at a private tertiary hospital in Kenya. Methods We conducted a retrospective chart review of all URVs within 72 hours among paediatric patients aged ≤15 years between 1 July and 31 December 2018 at the tertiary hospital in Nairobi, Kenya. Results During the study period, 1.6% (n=172) of patients who visited the PEC returned within 72 hours, with 4.7% revisiting the PEC more than once. Patients’ median age was 36 months (interquartile range: 42 months); over half were male (51.7%), 55.8% were ambulatory and 84.3% were insured. In addition, 21% (n=36) had chronic diseases and 7% (n=12) had drug allergies. Respiratory (59.5%) and gastrointestinal (21.5%) tract infections were the most common diagnoses. Compared with the first visit, more patients with URVs were classified as urgent (1.7% vs. 5.2%) and were non-ambulatory (44.2% vs. 49.5%, p=<0.001); 18% of these patients were admitted. Of these 58% were male, 83.9% were aged 0–5 years, 12.9% were classified as urgent, 64.5% had respiratory tract infections and 16.1% had gastrointestinal tract infections. Being admitted was associated with patient acuity (p=0.004), laboratory tests (p=<0.001) and ambulatory status (p=0.041). Conclusion The URV rate is low in our setting. Patients who returned to the PEC within 72 hours tended to be male, under 5 years old and insured. Many were non-urgent cases with diagnoses of respiratory and gastrointestinal tract infections. The findings suggest that some URVs were necessary and may have contributed to better care and improved outcomes while others highlight a need for effective patient education and comprehensive initial assessment.
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Marye S. Health insurance, pediatric asthma, and emergency department usage. Public Health Nurs 2021; 38:931-940. [PMID: 34020508 DOI: 10.1111/phn.12926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/23/2021] [Accepted: 04/23/2021] [Indexed: 11/28/2022]
Abstract
This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10 years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.
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Giusto J, Anton M, Gaiazov S, Huddleston K, Levy S, Fuller A, Hourigan S, Niederhuber J, Hwang V. Maternal Confidence and Emergency Department Utilization Among Infants. Pediatr Emerg Care 2021; 37:260-264. [PMID: 33903286 PMCID: PMC8083161 DOI: 10.1097/pec.0000000000002419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine if maternal confidence affects emergency department (ED) utilization in the first year of life. METHODS This retrospective cohort study examined the Maternal Confidence Questionnaire responses from a longitudinal birth cohort study and ED visits for these subjects across all Inova hospitals from January 2012 to July 2017 for full-term children 12 months or younger at the time of visit. Using logistic regression, maternal confidence, maternal race/ethnicity, age, education, parity, and insurance were evaluated against Emergency Severity Index acuity levels and ED visit frequency. RESULTS Of 2429 participants in the longitudinal study, 316 subjects visited the ED and met inclusion criteria. Medicaid status was the main factor associated with any ED visit. Low maternal confidence did not correlate with more frequent or nonurgent ED visits. Higher maternal confidence scores were seen in Hispanic or Latino mothers and mothers with parity greater than 1. Hispanic or Latino mothers were more likely to have Medicaid and more likely to bring their child to the ED. Mothers with college education had lower maternal confidence scores, were less likely to visit the ED, but had higher acuity level visits. CONCLUSIONS Low maternal confidence did not correlate with frequent ED visits or nonurgent visits. Medicaid status was the main factor associated with any ED visit. Hispanic or Latino mothers had higher maternal confidence scores, were more likely to have Medicaid and more likely to bring their child to the ED.
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Affiliation(s)
- Jina Giusto
- From the Department of Pediatrics, Inova Children's Hospital
| | - Megan Anton
- From the Department of Pediatrics, Inova Children's Hospital
| | - Sabrina Gaiazov
- Inova Translational Medicine Institute (ITMI), Inova Health Systems, Falls Church
| | - Kathi Huddleston
- College of Health and Human Services, George Mason University, Fairfax
| | - Shira Levy
- Inova Translational Medicine Institute (ITMI), Inova Health Systems, Falls Church
| | - Alma Fuller
- College of Health and Human Services, George Mason University, Fairfax
| | - Suchitra Hourigan
- Inova Translational Medicine Institute (ITMI), Inova Health Systems, Falls Church
| | - John Niederhuber
- Inova Translational Medicine Institute (ITMI), Inova Health Systems, Falls Church
| | - Vivian Hwang
- Department of Emergency Medicine, Inova Fairfax Hospital, Falls Church, VA
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Merianos AL, Jandarov RA, Gordon JS, Lyons MS, Mahabee-Gittens EM. Healthcare resources attributable to child tobacco smoke exposure. PLoS One 2021; 16:e0247179. [PMID: 33621228 PMCID: PMC7901732 DOI: 10.1371/journal.pone.0247179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background Tobacco smoke exposure (TSE) places an economic toll on the U.S. healthcare system. There is a gap in the literature on pediatric emergency department (ED) and urgent care related healthcare costs and utilization specific to tobacco smoke-exposed patients. The objectives were to assess pediatric ED visits, urgent care visits and hospital admissions longitudinally, and baseline visit costs among tobacco smoke-exposed children (TSE group) relative to unexposed children (non-TSE group). Methods and findings We conducted a retrospective study using electronic medical records of 380 children ages 0–17 years in the TSE group compared to 1,140 in the non-TSE group propensity score matched via nearest neighbor search by child age, sex, race, and ethnicity. Linear and Poisson regression models were used. Overall, children had a mean of 0.19 (SE = 0.01) repeat visits within 30-days, and 0.69 (SE = 0.04) pediatric ED visits and 0.87 (SE = 0.03) urgent care visits over 12-months following their baseline visit. The percent of children with ≥ 1 urgent care visit was higher among the TSE group (52.4%) than the non-TSE group (45.1%, p = 0.01). Children in the TSE group (M = $1,136.97, SE = 76.44) had higher baseline pediatric ED visit costs than the non-TSE group (M = $1,018.96, SE = 125.51, p = 0.01). Overall, children had 0.08 (SE = 0.01) hospital admissions over 12-months, and the TSE group (M = 0.12, SE = 0.02) had higher mean admissions than the non-TSE group (M = 0.06, SE = 0.01, p = 0.02). The child TSE group was at 1.85 times increased risk of having hospital admissions (95% CI = 1.23, 2.79, p = 0.003) than the non-TSE group. Conclusions Tobacco smoke-exposed children had higher urgent care utilization and hospital admissions over 12-months, and higher pediatric ED costs at baseline. Pediatric ED visits, urgent care visits, and hospitalizations may be opportune times for initiating tobacco control interventions, which may result in reductions of preventable acute care visits.
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Affiliation(s)
- Ashley L. Merianos
- School of Human Services, University of Cincinnati, Cincinnati, Ohio, United States of America
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Roman A. Jandarov
- Department of Environmental and Public Health Sciences, Division of Biostatistics and Bioinformatics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Judith S. Gordon
- College of Nursing, The University of Arizona, Tucson, Arizona, United States of America
| | - Michael S. Lyons
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - E. Melinda Mahabee-Gittens
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
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Giannouchos TV, Washburn DJ, Gary JC, Foster MJ. Frequent emergency department use in the paediatric population: A systematic literature review. J Eval Clin Pract 2021; 27:193-203. [PMID: 32141125 DOI: 10.1111/jep.13382] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We systematically reviewed the literature on paediatric frequent emergency department (ED) users to identify and to synthesize characteristics and factors associated with frequent ED utilization among this population in the United States. METHODS We searched Medline (Ovid), CINAHL (Ebsco), and Embase (Ovid) to identify all relevant studies after 1990. We focused on US studies analysing paediatric frequent ED (PFED) users excluding those focused on specific subgroups. Two reviewers independently selected articles and extracted data on predisposing, enabling, behavioural, need and reinforcing factors. RESULTS Fifteen studies met the inclusion criteria. PFED users comprised 3% to 14% of all paediatric ED users and accounted for 9% to 42% of all paediatric ED visits in 11 studies that defined frequent use as four to six ED visits per year. Most PFED users were less than 5 years old who had public insurance coverage and a regular provider. Public insurance compared to private residency in disadvantaged areas, having at least one chronic or complex condition and a history of hospitalization, were associated with frequent use. Children who had a regular primary care provider were less likely to exhibit frequent ED use. CONCLUSIONS Minimizing unnecessary ED visits by frequent utilizers is a quality improvement and cost-saving priority for health systems. Our findings indicate that many PFED users have greater healthcare needs and face barriers accessing care in a timely manner, even though some have regular providers. To better address the needs of this vulnerable group, health systems should focus on educating caregivers and expanding access to providers in other settings.
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Affiliation(s)
- Theodoros V Giannouchos
- School of Public Health, Department of Health Policy and Management, Texas A&M University, College Station, Texas, USA.,Population Informatics Lab, Texas A&M University, College Station, Texas, USA
| | - David J Washburn
- School of Public Health, Department of Health Policy and Management, Texas A&M University, College Station, Texas, USA
| | - Jodie C Gary
- Health Science Center College of Nursing, Texas A&M University, Bryan, Texas, USA
| | - Margaret J Foster
- Medical Sciences Library, Texas A&M University, College Station, Texas, USA
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Procter AM, Gialamas A, Pilkington RM, Montgomerie A, Chittleborough CR, Smithers LG, Lynch JW. Characteristics of paediatric frequent presenters at emergency departments: A whole-of-population study. J Paediatr Child Health 2021; 57:64-72. [PMID: 32815640 DOI: 10.1111/jpc.15119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022]
Abstract
AIM To quantify the frequency of emergency department (ED) presentations and profile the socio-demographic, health and presentation characteristics of paediatric ED frequent presenters. METHODS A population-based data linkage study of 55 921 children in the South Australian Early Childhood Data Project aged 0-12 years with 100 976 presentations to public hospital EDs in South Australia. For each child, the total number of recurrent ED presentations during a 364-day period post-index presentation was calculated. Frequent presenters were children who experienced ≥4 recurrent ED presentations. We determined the socio-demographic, health and presentation characteristics by number of recurrent presentations. RESULTS Children with ≥4 recurrent presentations (4.4%) accounted for 15.4% of all paediatric ED presentations and 22.5% of subsequent admissions to hospital during the 12-month study period. Compared to children with no recurrent ED presentation, frequent presenters had higher proportions of socio-economic and health disadvantage at birth. One in two (49.3%) frequent presenters had at least one injury presentation and one (21.3%) in five had at least one presentation related to a chronic condition. CONCLUSIONS Children with ≥4 presentations do not represent the majority of ED users. Nevertheless, they represent a disproportionate burden accounting for 15% of all paediatric ED presentations in a 12-month period. Frequent presenters were characterised by early socio-economic and health disadvantage, and childhood injury. Strategies targeting social disadvantage and childhood injury may reduce the burden of ED presentations.
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Affiliation(s)
- Alexandra M Procter
- School of Public Health, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Angela Gialamas
- School of Public Health, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rhiannon M Pilkington
- School of Public Health, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alicia Montgomerie
- School of Public Health, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Catherine R Chittleborough
- School of Public Health, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa G Smithers
- School of Public Health, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - John W Lynch
- School of Public Health, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia.,Population Health Sciences, University of Bristol, Bristol, United Kingdom
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Ambalavanan N, Jauk V, Szychowski JM, Boggess KA, Saade G, Longo S, Esplin S, Cleary K, Wapner R, Letson K, Owens M, Blackwell S, Andrews W, Tita AT. Epidemiology of readmissions in early infancy following nonelective cesarean delivery. J Perinatol 2021; 41:24-31. [PMID: 32669643 PMCID: PMC7854783 DOI: 10.1038/s41372-020-0730-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
Abstract
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).
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Affiliation(s)
| | - Victoria Jauk
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Jeff M. Szychowski
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Department of Biostatistics, University of Alabama at Birmingham
| | - Kim A. Boggess
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, Chapel Hill (K.B.)
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston (G.S.)
| | - Sherri Longo
- Department of Obstetrics and Gynecology, Ochsner Health System, New Orleans (S.L.)
| | - Sean Esplin
- Department of Obstetrics and Gynecology, University of Utah (S.E.) and Intermountain Health Care (S.E.), Salt Lake City
| | - Kirsten Cleary
- Department of Obstetrics and Gynecology, Columbia University, New York (K.C., R.W.)
| | - Ronald Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York (K.C., R.W.)
| | - Kellett Letson
- Department of Obstetrics and Gynecology, Mission Hospital, Asheville (K.L.)
| | - Michelle Owens
- Department of Obstetrics and Gynecology, University of Mississippi, Jackson (M.O.)
| | - Sean Blackwell
- Department of Obstetrics and Gynecology, University of Texas Health Sciences Center, Houston (S.B.)
| | - William Andrews
- Department of Biostatistics, University of Alabama at Birmingham
| | - Alan T. Tita
- Department of Biostatistics, University of Alabama at Birmingham
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Greenfield G, Blair M, Aylin PP, Saxena S, Majeed A, Bottle A. Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data. Emerg Med J 2020; 38:146-150. [PMID: 33199272 DOI: 10.1136/emermed-2019-209122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/03/2020] [Accepted: 10/04/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Frequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users in EDs. AIM To describe the volume of frequent paediatric attendance in England and the demographics of frequent paediatric ED users in English hospitals. METHOD We analysed the Hospital Episode Statistics dataset for April 2014-March 2017. The study included 2 308 816 children under 16 years old who attended an ED at least once. Children who attended four times or more in 2015/2016 were classified as frequent users. The preceding and subsequent years were used to capture attendances bordering with the current year. We used a mixed effects logistic regression with a random intercept to predict the odds of being a frequent user in children from different sociodemographic groups. RESULTS One in 11 children (9.1%) who attended an ED attended four times or more in a year. Infants had a greater likelihood of being a frequent attender (OR 3.24, 95% CI 3.19 to 3.30 vs 5 to 9 years old). Children from more deprived areas had a greater likelihood of being a frequent attender (OR 1.57, 95% CI 1.54 to 1.59 vs least deprived). Boys had a slightly greater likelihood than girls (OR 1.05, 95% CI 1.04 to 1.06). Children of Asian and mixed ethnic groups were more likely to be frequent users than those from white ethnic groups, while children from black and 'other' had a lower likelihood (OR 1.03, 95% CI 1.01 to 1.05; OR 1.04, 95% CI 1.01 to 1.06; OR 0.88, 95% CI 0.86 to 0.90; OR 0.90, 95% CI 0.87 to 0.92, respectively). CONCLUSION One in 11 children was a frequent attender. Interventions for reducing paediatric frequent attendance need to target infants and families living in deprived areas.
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Affiliation(s)
- Geva Greenfield
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Mitch Blair
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Paul P Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Alex Bottle
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Zhou AZ, Marin JR, Hickey RW, Ramgopal S. Serious Diagnoses for Headaches After ED Discharge. Pediatrics 2020; 146:peds.2020-1647. [PMID: 33008843 DOI: 10.1542/peds.2020-1647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits. METHODS We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. RESULTS Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8-15.4), 608 (0.5%, 95% confidence interval: 0.5%-0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs (P < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%-0.1%) (P < .001 for each). CONCLUSIONS A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.
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Affiliation(s)
- Amy Z Zhou
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Burns RR, Alpern ER, Rodean J, Canares T, Lee BR, Hall M, Montalbano A. Factors Associated With Urgent Care Reliance and Outpatient Health Care Use Among Children Enrolled in Medicaid. JAMA Netw Open 2020; 3:e204185. [PMID: 32374396 PMCID: PMC7203605 DOI: 10.1001/jamanetworkopen.2020.4185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/04/2020] [Indexed: 11/30/2022] Open
Abstract
Importance Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. Objectives To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. Design, Setting, and Participants A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. Exposures Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services. Main Outcomes and Measures Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. Results Of 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. Conclusions and Relevance High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.
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Affiliation(s)
- Rebecca R. Burns
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Jonathan Rodean
- Division of Analytics, Children’s Hospital Association, Lenexa, Kansas
| | - Therese Canares
- Division of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian R. Lee
- Health Outcomes and Health Services Research, Children’s Mercy, Kansas City, Missouri
| | - Matt Hall
- Division of Analytics, Children’s Hospital Association, Lenexa, Kansas
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A Predictive Model for Identification of Children at Risk of Subsequent High-Frequency Utilization of the Emergency Department for Asthma. Pediatr Emerg Care 2020; 36:e85-e89. [PMID: 31181024 PMCID: PMC6895410 DOI: 10.1097/pec.0000000000001866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Asthma is the most common chronic condition among children with high-frequency emergency department (ED) utilization. Previous research has shown in outpatients seen for asthma that acute care visits predict subsequent health care utilization. Among ED patients, however, the optimal method of predicting subsequent ED utilization remains to be described. The goal of this study was to create a predictive model to identify children in the ED who are at risk of subsequent high-frequency utilization of the ED for asthma. METHODS We used 3 years of data, 2013-2015, drawn from the electronic health records at a tertiary care, urban, children's hospital that is a high-volume center for asthma care. Data were split into a derivation (50%) and validation/test (50%) set, and 3 models were created for testing: (1) all index patients; (2) removing patients with complex chronic conditions; and (3) subset of patients with in-network care on whom more clinical data were available. Each multivariable model was then tested in the validation set, and its performance evaluated by predicting error rate, calculation of a receiver operating characteristic (ROC) curve, and identification of the optimal cutpoint to maximize sensitivity and specificity. RESULTS There were 5535 patients with index ED visits, of whom 2767 were in the derivation set and 2768 in the validation set. Of the 5535 patients, 125 patients (2.3%) had 4 or more visits for asthma in the outcome year. Significant predictors in models 1 and 2 were age and number of prior ED visits for asthma. For model 3 (additional clinical information available), the predictors were number of prior ED visits for asthma, number of primary care visits, and not having a controller medication. Areas under the ROC curve were 0.77 for model 1, 0.80 for model 2, and 0.77 for model 3. CONCLUSIONS Administrative data available at the time of ED triage can predict subsequent high utilization of the ED, with areas under the ROC curve of 0.77 to 0.80. The addition of clinical variables did not improve the model performance. These models provide useful tools for researchers interested in examining intervention efficacy by predicted risk group.
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