Effects of immigrant status on Emergency Room (ER) utilisation by children under age one: a population-based study in the province of Reggio Emilia (Italy)

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

OBJECTIVE

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

DESIGN

A retrospective cohort study.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Rates of emergency room visits and hospitalizations among refugee and resident children in a tertiary hospital in Turkey

Evaluation of emergency department (ED) presentation by Syrian refugee children might provide important information about their health care needs. For this purpose, we compared ED presentation of refugee and resident children in a tertiary university hospital in Istanbul, Turkey.Electronic medical records of Syrian refugee children ≤ 18 years old presenting to the ED between January 2013 and July 2019 were retrospectively reviewed and compared with resident children.The study population consisted of 7299 refugees and 690,127 resident children admitted to the ED. High-acuity cases were more frequent in Syrian refugees (2.2% vs 1% p < 0.001). One-third of Syrian children were under 12 months of age (31% vs 17%, p < 0.001). Syrian children were more commonly hospitalized (7.9% vs 3.1% p < 0.001). The median age (and interquartile range - IQR) was lower in hospitalized refugee than in resident children [12 (0-83) months vs 41 (8-111) months, p < 0.001]. Rate of intensive care unit hospitalization (13% vs 9.4%, p = 0.001) and neonatal hospitalization was higher in Syrians compared to resident children (29% vs 12%, p < 0.001). The median NICU stay was longer in refugees [6 (IQR 4-17) days vs 3 (IQR 1-9) days, p < 0.001].

CONCLUSION

Refugee children, as compared to resident children, are more likely to present to the ED with high acuity conditions and at a younger age resulting in higher rates of inpatient admissions. Strategies to increase access to preventive health care services for young refugee children should be explored to decrease ED and hospital services and improve health outcomes.

WHAT IS KNOWN

• Children are the most affected victims of armed conflicts in terms of health outcomes. • Refugees prefer to access healthcare through the emergency department.

WHAT IS NEW

• Refugee children were more likely to present as urgent when compared to resident children. • Admission to neonatal and intensive care units was more frequent among refugee than resident children.

Clinical and imaging characteristics of patients with COVID-19 predicting hospital readmission after emergency department discharge: a single-centre cohort study in Italy

OBJECTIVE

We aimed at identifying baseline predictive factors for emergency department (ED) readmission, with hospitalisation/death, in patients with COVID-19 previously discharged from the ED. We also developed a disease progression velocity index.

DESIGN AND SETTING

Retrospective cohort study of prospectively collected data. The charts of consecutive patients with COVID-19 discharged from the Reggio Emilia (Italy) ED (2 March 2 to 31 March 2020) were retrospectively examined. Clinical, laboratory and CT findings at first ED admission were tested as predictive factors using multivariable logistic models. We divided CT extension by days from symptom onset to build a synthetic velocity index.

PARTICIPANTS

450 patients discharged from the ED with diagnosis of COVID-19.

MAIN OUTCOME MEASURE

ED readmission within 14 days, followed by hospitalisation/death.

RESULTS

Of the discharged patients, 84 (18.7%) were readmitted to the ED, 61 (13.6%) were hospitalised and 10 (2.2%) died. Age (OR=1.05; 95% CI 1.03 to 1.08), Charlson Comorbidity Index 3 versus 0 (OR=11.61; 95% CI 1.76 to 76.58), days from symptom onset (OR for 1-day increase=0.81; 95% CI 0.73 to 0.90) and CT extension (OR for 1% increase=1.03; 95% CI 1.01 to 1.06) were associated in a multivariable model for readmission with hospitalisation/death. A 2-day lag velocity index was a strong predictor (OR for unit increase=1.21, 95% CI 1.08 to 1.36); the model including this index resulted in less information loss.

CONCLUSIONS

A velocity index combining CT extension and days from symptom onset predicts disease progression in patients with COVID-19. For example, a 20% CT extension 3 days after symptom onset has the same risk as does 50% after 10 days.

[Maternal and child health inequalities among migrants: the case of Haiti and the Dominican RepublicDesigualdades na saúde materno-infantil entre migrantes: o caso do Haiti e da República Dominicana]

Objective

To assess coverage and inequalities in maternal and child health interventions among Haitians, Haitian migrants in the Dominican Republic and Dominicans.

Methods

Cross-sectional study using data from nationally representative surveys carried out in Haiti in 2012 and in the Dominican Republic in 2014. Nine indicators were compared: demand for family planning satisfied with modern methods, antenatal care, delivery care (skilled birth attendance), child vaccination (BCG, measles and DPT3), child case management (oral rehydration salts for diarrhea and careseeking for suspected pneumonia), and the composite coverage index. Wealth was measured through an asset-based index, divided into tertiles, and place of residence (urban or rural) was established according to the country definition.

Results

Haitians showed the lowest coverage for demand for family planning satisfied with modern methods (44.2%), antenatal care (65.3%), skilled birth attendance (39.5%) and careseeking for suspected pneumonia (37.9%), and the highest for oral rehydration salts for diarrhea (52.9%), whereas Haitian migrants had the lowest coverage in DPT3 (44.1%) and oral rehydration salts for diarrhea (38%) and the highest in careseeking for suspected pneumonia (80.7%). Dominicans presented the highest coverage for most indicators, except oral rehydration salts for diarrhea and careseeking for suspected pneumonia. The composite coverage index was 79.2% for Dominicans, 69.0% for Haitian migrants, and 52.6% for Haitians. Socioeconomic inequalities generally had pro-rich and pro-urban pattern in all analyzed groups.

Conclusion

Haitian migrants presented higher coverage than Haitians, but lower than Dominicans. Both countries should plan actions and policies to increase coverage and address inequalities of maternal health interventions.

Frequency of health-care service use and severity of illness in undocumented migrants in Catalonia, Spain: a population-based, cross-sectional study

BACKGROUND

In Spain, legislation was passed in 2012 excluding undocumented migrants from the public health-care system. Catalonia was one of the Spanish regions that did not implement this legislation, and continued to guarantee access to health care to the whole population. We aimed to analyse health-care use and health status among undocumented migrants in Catalonia, and compare health-care use and health status with legal residents classified according to their socioeconomic position (SEP).

METHODS

We did a population-based, cross-sectional study, with administrative individual data. The study included the resident population in Catalonia, Spain, in 2017, aged younger than 65 years and with a maximum annual income of less than €18 000 per year, and classified into three socioeconomic (SEP) groups-low SEP, very low SEP, and undocumented migrants. Indicators regarding health-care service use (primary care, emergency care, mental health care, acute care), drug prescriptions, and selected chronic and infectious diseases were analysed.

FINDINGS

Between Jan 1 and Dec 31, 2017, 4 071 988 residents of Catalonia were included in this study; undocumented migrants represented 2·8% (n=113 450) of this population. Of all undocumented migrants, 25 942 (61·0%) female participants aged 15-64 years and 19 819 (46·0%) male participants aged 15-64 years attended primary health-care centres: these rates were lower than in individuals with a very low SEP (84·8% in female participants and 72·1% in male participants). Hospital admission rates among male participants aged 15-64 years in the very low SEP group were more than three times as high as in undocumented migrants (111·6 vs 35·7). The highest tuberculosis rate was found in undocumented male migrants (incidence rate 4·35 [95% CI 3·55-5·16]).

INTERPRETATION

Undocumented migrants made less use of health-care services than those in the low and very low SEP groups, but for some infectious diseases, incidence was higher in undocumented migrants. These results constitute an additional argument to support the maintenance of universal health coverage for all citizens.

FUNDING

None.

Explaining variation in health information seeking behaviour - Insights from a multilingual survey

OBJECTIVE

How best to provide an increasingly diverse population with health information has become a major concern for health policy makers in Europe and beyond. Our study aims to investigate factors explaining variation in people's health information seeking behaviour. Our findings can be used to identify target groups for policy interventions that aim to provide health information efficiently.

METHODS

Cross-sectional, paper-based, multilingual survey of a random sample of enrolees of two statutory health insurers in Hamburg, Germany. Data were collected from September to December 2017. Multivariable logistic regression was used to examine sociodemographic and health-related individual characteristics and their associations with participants' choice of ten sources of health information.

FINDINGS

Participants' choice of information sources differed significantly across the following sociodemographic and health-related characteristics: age, gender, immigration status, education, employment status, marital status and general state of health. Immigrants and individuals with low educational attainment were most likely to use emergency departments as sources of health information.

CONCLUSION

Policy interventions aiming to manage the use of health information sources should focus on immigrants and individuals with low educational attainment. Providing multilingual, low-threshold counselling and information services could be an efficient way to reduce short-term costs of health information seeking behaviour to health insurers or other payers of care while improving patient empowerment.

Adequate Utilization of Emergency Services in Germany: Is There a Differential by Migration Background?

Background: The role of emergency services (ES) is to provide round-the-clock acute care. In recent years, inadequate use of ES has been internationally thematised because of overcrowding and the associated cost. Evidence shows that migrant populations tend to use more ES than non-migrant but it remains to show if there is a differential in inadequacy.

Method: Quantitative data from consecutive patients visiting three ES in Berlin (hospital-based outpatient clinics for internal medicine or gynecology) from July 2017 to July 2018 were obtained. Utilization was defined as adequate if the patient was admitted to hospital and/or if all of the three following criteria were fulfilled: reported to have been sent by medical staff; reported strong pain; and reported a high urgency (both ≥7, scale from 0 to 10). Differences between migrants (1st generation), their offspring (2nd generation), and non-migrants were evaluated using logistic regression.

Results: Of the 2,327 patients included, 901 had a migration background. Adjusting for gender, age, gynecological hospital-based outpatient clinic, and the number of chronic diseases, 1st generation migrant patients (n = 633) had significantly lower odds than non-migrants to have an adequate utilization of services [OR 0.78, 95% confidence interval (0.62, 0.99), p-value 0.046]. For 2nd generation patients (n = 268), no statistically significant difference was found [OR 0.80, 95% confidence interval (0.56, 1.15), p-value 0.231]. Only adjusting for gynecological hospital-based outpatient clinic did weaken the association between migration status on adequacy but interactions between type of hospital-based outpatient clinic and migration were not significant.

Discussion: First generation migrants show lower odds of adequate ES use compared to non-migrants. Only visiting a gynecological hospital-based outpatient clinic as opposed to internal medicine could partly explain the lower odds of adequate use among immigrants. This indicates a need for structural changes in the healthcare system: The threshold of access to general practices needs to be lowered, considering the needs of diverse subgroups of migrant patients.

Maternal and child health inequalities among migrants: the case of Haiti and the Dominican Republic

Objective.

To assess coverage and inequalities in maternal and child health interventions among Haitians, Haitian migrants in the Dominican Republic and Dominicans.

Methods.

Cross-sectional study using data from nationally representative surveys carried out in Haiti in 2012 and in the Dominican Republic in 2014. Nine indicators were compared: demand for family planning satisfied with modern methods, antenatal care, delivery care (skilled birth attendance), child vaccination (BCG, measles and DPT3), child case management (oral rehydration salts for diarrhea and careseeking for suspected pneumonia), and the composite coverage index. Wealth was measured through an asset-based index, divided into tertiles, and place of residence (urban or rural) was established according to the country definition.

Results.

Haitians showed the lowest coverage for demand for family planning satisfied with modern methods (44.2%), antenatal care (65.3%), skilled birth attendance (39.5%) and careseeking for suspected pneumonia (37.9%), and the highest for oral rehydration salts for diarrhea (52.9%), whereas Haitian migrants had the lowest coverage in DPT3 (44.1%) and oral rehydration salts for diarrhea (38%) and the highest in careseeking for suspected pneumonia (80.7%). Dominicans presented the highest coverage for most indicators, except oral rehydration salts for diarrhea and careseeking for suspected pneumonia. The composite coverage index was 79.2% for Dominicans, 69.0% for Haitian migrants, and 52.6% for Haitians. Socioeconomic inequalities generally had pro-rich and pro-urban pattern in all analyzed groups.

Conclusion.

Haitian migrants presented higher coverage than Haitians, but lower than Dominicans. Both countries should plan actions and policies to increase coverage and address inequalities of maternal health interventions.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status

OBJECTIVE

To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge.

STUDY DESIGN

This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37 weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5 days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors.

RESULTS

Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5 years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits.

CONCLUSIONS

Among immigrant mothers, non-English primary language, >5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Asylum Seekers and Swiss Nationals with Low-Acuity Complaints: Disparities in the Perceived level of Urgency, Health Literacy and Ability to Communicate-A Cross-Sectional Survey at a Tertiary Emergency Department

Background: Emergency departments (EDs) are being increasingly used for low-acuity conditions and as primary care providers. Research indicates that patients with the status of asylum seeker (AS) may be seeking care in EDs at higher levels than nationals. The aim of this study was to identify disparities in the use of emergency care between AS and Swiss nationals (SN) with non-urgent complaints. Methods: Data were obtained from a survey in the period 01/12/2016–31/07/2017 of walk-in low-acuity patients attending the ED of the University Hospital Bern (Switzerland). AS and a gender, age-matched control group of SN of ≥16 years of age were included. Sociodemographic and survey data comprised information about health-seeking behavior in the home and reception country, knowledge of health care systems (HCSs), barriers to care and perceived acuity of the visit. Furthermore, attending physicians assessed the level of urgency of each case. Results: Among AS patients, 30.2% reported that they had no knowledge of the Swiss HCS. In total, 14.2% considered that their medical needs were non-urgent. On the other hand, 43.4% of the attending physicians in the ER considered that the medical needs were non-urgent. This contrast was less pronounced in SN patients. The majority of AS (63.2%) and SN (67.6%) patients sought care from the ED without first contacting a GP. In 53.8% of cases, an interpreter was needed during the ED consultation. Conclusions: Several factors associated with health-seeking behavior in the ED differed between AS and SN patients. Measures to increase health literacy, provision of easily accessible primary care services and intercultural-trained staff could improve quality of care and reduce the usage of EDs as primary care providers.

Paediatric emergency department utilisation rates and maternal migration status in the Born in Bradford cohort: A cross-sectional study

BACKGROUND

Globally, international migration is increasing. Population growth, along with other demographic changes, may be expected to put new pressures on healthcare systems. Some studies across Europe suggest that emergency departments (EDs) are used more, and differently, by migrants compared to non-migrant populations, which may be a result of unfamiliarity with the healthcare systems and difficulties accessing primary healthcare. However, little evidence exists to understand how migrant parents, who are typically young and of childbearing age, utilise EDs for their children. This study aimed to examine the association between paediatric ED utilisation in the first 5 years of life and maternal migration status in the Born in Bradford (BiB) cohort study.

METHODS AND FINDINGS

We analysed linked data from the BiB study-an ongoing, multi-ethnic prospective birth cohort study in Bradford. Bradford is a large, ethnically diverse city in the north of England. In 2017, more than a third of births in Bradford were to mothers who were born outside the UK. Between March 2007 and December 2010, pregnant women were recruited to BiB during routine antenatal care, and the children born to these mothers have been, and continue to be, followed over time to assess how social, genetic, environmental, and behavioural factors impact on health from childhood to adulthood. Data analysed in this study included baseline questionnaire data from BiB mothers, and Bradford Royal Infirmary ED episode data for their children. Main outcomes were likelihood of paediatric ED use (no visits versus at least 1 ED visit in the first 5 years of life) and ED utilisation rates (number and frequency of ED visits) for children who have accessed the ED. The main explanatory variable was mother's migrant status (foreign-born versus UK/Irish-born). Multivariable analyses (logistic and zero-truncated negative binomial regression) were conducted adjusting for socio-demographic and socio-economic factors. The final dataset included 10,168 children born between April 2007 and June 2011, of whom 35.6% were born to migrant mothers. Foreign-born mothers originated from South Asia (28.6%), Europe/Central Asia (3.2%), Africa (2.1%), East Asia/Pacific (1.1%), and the Middle East (0.6%). At recruitment the mothers ranged in age from 15 to 49 years old. Overall, 3,104 (30.5%) children had at least 1 ED visit in the first 5 years of life, with the highest proportion of visits being in the first year of life (36.7%). The proportion of children who visited the ED at least once was lower for children of migrant mothers as compared to children of non-migrant mothers (29.4% versus 31.2%). Children of migrant mothers were found to be less likely to visit the ED (odds ratio 0.88 [95% CI 0.80 to 0.97], p = 0.012). However, among children who visited the ED, the utilisation rate was significantly higher for children of migrant mothers (incidence rate ratio [IRR] 1.19 [95% CI 1.01 to 1.40], p = 0.040). Utilisation rates were higher for children born to mothers from Europe (IRR 1.71 [95% CI 1.07 to 2.71], p = 0.024) and established migrants (≥5 years living in UK) (IRR 1.24 [95% CI 1.02 to 1.51], p = 0.032) compared to UK/Irish-born mothers. Important limitations include being unable to measure children's underlying health status and the urgency of ED attendance, as well as the analysis being limited by missing data.

CONCLUSIONS

In this study we observed that there is no higher likelihood of first paediatric ED attendance in the first 5 years of life for children in the BiB cohort for migrant mothers. However, among ED users, children of migrant mothers attend the service more frequently than children of UK/Irish-born mothers. Our findings show that patterns of ED utilisation differ by mother's region of origin and time since arrival in the UK.

Non-urgent paediatric emergency department presentation: A systematic review

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

International migrants' use of emergency departments in Europe compared with non-migrants' use: a systematic review

Background

International migration across Europe is increasing. High rates of net migration may be expected to increase pressure on healthcare services, including emergency services. However, the extent to which immigration creates additional pressure on emergency departments (EDs) is widely debated. This review synthesizes the evidence relating to international migrants' use of EDs in European Economic Area (EEA) countries as compared with that of non-migrants.

Methods

MEDLINE, EMBASE, CINAHL, The Cochrane Library and The Web of Science were searched for the years 2000-16. Studies reporting on ED service utilization by international immigrants, as compared with non-migrants, were eligible for inclusion. Included studies were restricted to those conducted in EEA countries and English language publications only.

Results

Twenty-two articles (from six host countries) were included. Thirteen of 18 articles reported higher volume of ED service use by immigrants, or some immigrant sub-groups. Migrants were seen to be significantly more likely to present to the ED during unsocial hours and more likely than non-migrants to use the ED for low-acuity presentations. Differences in presenting conditions were seen in 4/7 articles; notably a higher rate of obstetric and gynaecology presentations among migrant women.

Conclusions

The principal finding of this review is that migrants utilize the ED more, and differently, to the native populations in EEA countries. The higher use of the ED for low-acuity presentations and the use of the ED during unsocial hours suggest that barriers to primary healthcare may be driving the higher use of these emergency services although further research is needed.

Influence of social characteristics on use of paediatric emergency care in Sweden - a questionnaire based study

Background

Parental social characteristics influence the use of emergency departments (ED) in the USA, but less is known about paediatric ED care-seeking in countries with national health insurance. This prospective study was designed to evaluate associations between parental care-seeking and social characteristics, with emphasis on impact of non-native origin, at a paediatric ED in Sweden, a European country providing paediatric healthcare free of charge.

Methods

Parents attending a paediatric ED at a large urban university hospital filled out a questionnaire on social characteristics and reasons for care-seeking. Information on patient characteristics and initial management was obtained from ED registers and patient records. Paediatric ED physicians assessed the medical appropriateness of each patient visit triaged for ED care.

Results

In total, 962 patient visits were included. Telephone healthline service before the paediatric ED visit was less often used by non-native parents (63/345 vs. 249/544, p < 0.001). Low-aquity visits, triaged away from the ED, were more common among non-native parents (80/368 vs. 67/555, OR = 1.66; p = 0.018), and among those reporting lower abilities in the Swedish language (23/82 vs. 120/837, OR = 2.66; p = 0.003). Children of non-native parents were more often assessed by physicians not to require ED care (122/335 vs. 261/512, OR = 0.70; p = 0.028).

Conclusions

This study confirms more direct and less urgent use of paediatric ED care by parents of non-native origin or with limited abilities in the Swedish language, proposing that parental social characteristics influence paediatric ED care-seeking, also in a country with healthcare free of charge, and that specific needs of these groups should be better met by prehospital medical services.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0210-5) contains supplementary material, which is available to authorized users.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of health services among international migrant children - a systematic review

BACKGROUND

Migrant children have specific health needs, and may face difficulties in accessing health care, but not enough is known about their health service use. This study aims to describe patterns of use of health services of international migrant children and differences to respective native populations.

METHODS

Electronic databases PubMed and Web of Science, references of identified publications, and websites of relevant international agencies were searched. We included observational studies published between 2006 and 2016 that reported use of formal health services by migrant children (0-18 years), including first and second generation migrants. Data on study characteristics, study theme, main outcome and study quality were extracted.

RESULTS

One hundred seven full texts were included in the review. Of the studies that reported comparable outcomes, half (50%) indicated less use of healthcare by migrants compared with non-migrants; 25% reported no difference, 18% reported greater use, and 7% did not report this outcome. There was variation by theme, so that the proportion of conclusions "less use" was most common in the categories "general access to care", "primary care" and "oral health", whereas in the use of emergency rooms or hospitalisations, the most common conclusion was "greater use".

CONCLUSIONS

Migrant children appear to use different types of healthcare services less than native populations, with the exception of emergency and hospital services.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO systematic review registration number: CRD42016039876 .

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reasons for attending a general emergency outpatient clinic versus a regular general practitioner - a survey among immigrant and native walk-in patients in Oslo, Norway

OBJECTIVE

To explore reasons for attending a general emergency outpatient clinic versus a regular general practitioner (RGP).

DESIGN

Cross-sectional study using a multilingual anonymous questionnaire.

SETTING

Native and immigrant walk-in patients attending a general emergency outpatient clinic in Oslo (Monday-Friday, 08:00-23:00) during 2 weeks in September 2009.

SUBJECTS

We included 1022 walk-in patients: 565 native Norwegians (55%) and 457 immigrants (45%).

MAIN OUTCOME MEASURES

Patients' reasons for attending an emergency outpatient clinic versus their RGP.

RESULTS

Among patients reporting an RGP affiliation, 49% tried to contact their RGP before this emergency encounter: 44% of native Norwegian and 58% of immigrant respondents. Immigrants from Africa [odds ratio (OR) = 2.55 (95% confidence interval [CI]: 1.46-4.46)] and Asia [OR = 2.32 (95% CI: 1.42-3.78)] were more likely to contact their RGP before attending the general emergency outpatient clinic compared with native Norwegians. The most frequent reason for attending the emergency clinic was difficulty making an immediate appointment with their RGP. A frequent reason for not contacting an RGP was lack of access: 21% of the native Norwegians versus 4% of the immigrants claimed their RGP was in another district/municipality, and 31% of the immigrants reported a lack of affiliation with the RGP scheme.

CONCLUSIONS AND IMPLICATIONS

Access to primary care provided by an RGP affects patients' use of emergency health care services. To facilitate continuity of health care, policymakers should emphasize initiatives to improve access to primary health care services. KEY POINTS Access to immediate primary health care provided by a regular general practitioner (RGP) can reduce patients' use of emergency health care services. The main reason for attending a general emergency outpatient clinic was difficulty obtaining an immediate appointment with an RGP. A frequent reason for native Norwegians attending a general emergency outpatient clinic during the daytime is having an RGP outside Oslo. Lack of affiliation with the RGP scheme is a frequent reason for attending a general emergency outpatient clinic among immigrants.

Primary healthcare usage and use of medications among immigrant children according to age of arrival to Norway: a population-based study

BACKGROUND

Morbidity, use of healthcare and medication use have been reported to vary across groups of migrants and according to the different phases of migration, but little is known about children with immigrant background. In this study, we investigate whether the immigrant children's age of arrival predicts differences in usage of primary healthcare (PHC) and in use of prescribed medication.

METHODS

This nationwide, population-based study used information for children under 18 years of age in 2008 from three linked registers in Norway. Use of medication was assessed with logistic regression analyses presented with ORs with 95% CIs.

RESULTS

Of 1 168 365 children, 119 251 had immigrant background. The mean number of PHC visits among children aged 10-18 years, was 1.19 for non-immigrants, 1.17 among second generation immigrants, 1.12, 1.05 and 0.83 among first immigrant children who were <5, 5-9 and ≥10 years at arrival in Norway, respectively. Patterns were similar for younger immigrants, and were confirmed with regression models adjusting for age and sex. First generation immigrant children used less of nearly all groups of prescribed medication compared to non-immigrants when adjusting for age and sex (overall OR 0.48 (0.47 to 0.49)), and medication was also generally less used among second generation immigrant children (overall OR 0.92 (0.91 to 0.94)).

CONCLUSIONS

Age of arrival predicted PHC usage among children among first-generation children. First-generation immigrant children, particularly those arriving later in adolescence, used PHC less than age corresponding non-immigrant children. Immigrant children used less prescribed medication compared to non-immigrants after adjustment for age and sex.

Factors associated with difficulty accessing health care for infants in Canada: mothers' reports from the cross-sectional Maternity Experiences Survey

Background

Approximately 13% of Canadian mothers report difficulty accessing health care for their infants, yet little is known about the factors associated with difficulty. Therefore, we examined factors associated with difficulty accessing non-routine health care for Canadian infants, from birth to 14 months of age, as reported by their mothers.

Methods

Data was drawn from the Maternity Experiences Survey (MES), a cross-sectional, nationally representative survey of mothers who gave birth between November 2005 and May 2006, aged 15 years or older, and lived with their infants at the time of survey administration. A multivariable logistic regression analysis was conducted to determine factors associated with reporting difficulty, with difficulty defined as a mother reporting it being somewhat or very difficult to access a health care provider.

Results

Analysis of 2832 mothers who reported needing to access a health care provider for their infant for a non-routine visit found that 13% reported difficulty accessing a provider. Factors associated with reporting difficulty were: residing in Quebec (aOR 1.89, 95% CI: 1.31–2.73), being an immigrant (aOR 1.58, 95% CI: 1.10–2.27), mistimed pregnancy (aOR 1.44, 95% CI: 1.05–1.98), low level of social support (aOR 1.69, 95% CI: 1.05–2.73), good health (aOR 1.88, 95% CI: 1.43–2.47), postpartum depression symptoms (aOR 1.55, 95% CI: 1.02–2.37) and a self-reported ‘too-short’ postpartum hospital stay (aOR 1.69, 95% CI: 1.21–2.35). Additionally, accessing care for an infant with a birth weight of 2500 g or more (aOR 2.43, 95% CI: 1.02–5.82), was associated with reporting difficulty. Household income, mothers’ level of education, marital status, Aboriginal ethnicity, and size of community of residence were not associated with difficulty accessing care.

Conclusions

Ease of health care access for Canadian infants is not equal, suggesting that efforts to improve access should be tailored to groups facing increased difficulties.

Primary healthcare usage and morbidity among immigrant children compared with non-immigrant children: a population-based study in Norway

OBJECTIVES

Health status, disease spectrum and use of healthcare have been reported to vary across groups of migrants and according to the different phases of migration. However, most studies are conducted among adults. This study assesses usage of primary healthcare (PHC) by children with immigrant background compared with non-immigrant children in Norway and describes their relative morbidity burden.

DESIGN

Population-based retrospective cohort study.

SETTING

This study used 3 linked population-based registers in Norway for children under 18 years of age in 2008.

MAIN EXPOSURE AND OUTCOME MEASURES

Immigrants were defined as children with both parents born abroad, and further classified into first and second generation, and according to the World Bank income categories of their parents' country of origin. Usage and morbidity were assessed with negative binomial regression and logistic regression analyses, respectively. Further, population-attributable fraction analyses on PHC visits were conducted to estimate the impact on the primary health system.

PARTICIPANTS

1 168 365 children including 119 251 with immigrant background.

RESULTS

The mean number of visits to PHC for non-immigrant children was 1.40 compared with 1.19 for immigrants from high-income countries (HIC) and 1.76 for immigrants from low-income countries (LIC). Compared with non-immigrants, first generation immigrants used PHC significantly less after adjusting for age and sex (incidence risk ratio (IRR) 0.70 (HIC) to 0.93 (LIC)) while second generation immigrant children generally used PHC more (IRR 1.03 (HIC) to 1.43 (LIC)); however, the median number of visits were similar between all groups. The morbidity spectrum also varied between the groups.

CONCLUSIONS

Compared with non-immigrants, the excess number of consultations attributable to immigrant groups corresponds to around 1.3% of PHC visits among children.

Is it a matter of urgency? A survey of assessments by walk-in patients and doctors of the urgency level of their encounters at a general emergency outpatient clinic in Oslo, Norway

Background

Emergency room (ER) use is increasing in several countries. Variability in the proportion of non-urgent ER visits was found to range from 5 to 90 % (median 32 %). Non-urgent emergency visits are considered an inappropriate and inefficient use of the health-care system because they may lead to higher expenses, crowding, treatment delays, and loss of continuity of health care provided by a general practitioner. Urgency levels of doctor–walk-in patient encounters were assessed based on their region of origin in a diverse Norwegian population.

Methods

An anonymous, multilingual questionnaire was distributed to all walk-in patients at a general emergency outpatient clinic in Oslo during two weeks in September 2009. We analysed demographic data, patient–doctor assessments of the level of urgency, and the results of the consultation. We used descriptive statistics to obtain frequencies with 95 % confidence interval (CI) for assessed levels of urgency and outcomes. Concordance between the patients’ and doctors’ assessments was analysed using a Kendall tau-b test. We used binary logistic regression modelling to quantify associations of explanatory variables and outcomes according to urgency level assessments.

Results

The analysis included 1821 walk-in patients. Twenty-four per cent of the patients considered their emergency consultation to be non-urgent, while the doctors considered 64 % of encounters to be non-urgent. The concordance between the assessments by the patient and by their doctor was positive but low, with a Kendall tau-b coefficient of 0.202 (p < 0.001). Adjusted logistic regression analysis showed that patients from Eastern Europe (odds ratio (OR) = 3.04; 95 % CI 1.60–5.78), Asia and Turkey (OR = 4.08; 95 % CI 2.43–6.84), and Africa (OR = 8.47; 95 % CI 3.87–18.5) reported significantly higher urgency levels compared with Norwegians. The doctors reported no significant difference in assessment of urgency based on the patient’s region of origin, except for Africans (OR = 0.64; 95 % CI 0.43–0.96).

Conclusion

This study reveals discrepancies between assessments by walk-in patients and doctors of the urgency level of their encounters at a general emergency clinic. The patients’ self-assessed perception of the urgency level was related to their region of origin.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-016-0086-1) contains supplementary material, which is available to authorized users.

Differences in diabetes prevalence and inequalities in disease management and glycaemic control by immigrant status: a population-based study (Italy)

Background

The diabetes prevalence increases at an alarming rate around the world and understanding disparities in occurrence, care management, and health outcomes may be a starting point towards achieving more effective strategies to prevent and manage it. The aims of this study are to compare immigrants and Italians in terms of the differences in diabetes prevalence and to evaluate inequalities in disease management and glycaemic control by using information included in Reggio Emilia diabetes register.

Methods

We retrieved from the diabetes register subjects aged 20–74 on December 31^st, 2009. Using citizenship, we created three main groups: Italy, High Developed Countries (HDC), and High Migration Pressure Countries (HMPC). These were split into sub-regions of origin. We calculated age-adjusted prevalence by gender and sub-region. Using logistic regression model, we analyzed the association between area of origin and following indicators: 1) not being in care of diabetes clinics; 2) not having glycated haemoglobin (HbA1c) test in 2010; 3) among those tested, having a HbA1c value > = 9% (75 mmol/mol).

Results

We found 15,889 Italian and 1,295 HMPC citizens with diabetes. HMPC citizens had higher age-adjusted prevalence of diabetes than Italians (females 5.0% vs 3.6%; males 6.5% vs 5.5%). The excess was mostly due to a strong excess in immigrants from Southern Asia (females 9.7%, males 10.2%) and Northern Africa (females 9.3%, males 5.9%). HMPC citizens were cared for by diabetes clinics in a similar proportion than Italians (OR: 1.08; 95% CI: 0.93-1.25), but had a greater odds of not being tested for HbA1c (OR: 1.51; 95% CI: 1.34-1.71), as well as of having HbA1c values equal to or over 9% (OR: 2.06; 95% CI: 1.80-3.14). The outcomes were poorer in HMPC females for the first two outcomes, while there was no difference for the HbA1c values (Wald test for heterogeneity p = 0.0850; p = 0.0156; p = 0.6635, respectively).

Conclusions

Our findings highlight the need for gender-oriented actions for prevention and early diagnosis of the diabetes to contrast the higher risk in Northern Africans and Southern Asians. Further studies are required to determine whether the protocols in use are adequate for different immigrant groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1403-4) contains supplementary material, which is available to authorized users.