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Medical emergencies

Reducing Pediatric Emergency Department Utilization

Author:

Jessica Tomaszewski, MD
Primary Care Pediatrics, Nemours Children’s Health System, Wilmington, Delaware

Citation:

Tomaszewski J. Reducing pediatric emergency department utilization [published online January 18, 2018]. Consultant for Pediatricians.

Flood C, Sheehan K, Crandall M. Predictors of emergency department utilization among children in vulnerable families. Pediatr Emerg Care. 2017;33(12):765-769.

Health care costs are an incredible challenge to the economic health of the United States. One source of particularly high health care spending is in the emergency department (ED). Recent reports in the literature suggest that ED spending could represent as much as 10% of overall health care costs.1 Many of these visits could be addressed in a less resource-intensive setting such as an outpatient office. Therefore, identifying factors associated with high ED utilization may lead to a greater understanding of health care delivery and health care costs.

To help understand the motivations of frequent ED visits, authors of previous studies have examined characteristics such as patients’ chronic conditions, frequent caregiver ED visits, race, and insurance status. To analyze all of these socioeconomic and medical factors simultaneously, Flood and colleagues2 used data from the Fragile Families and Child Wellbeing Study (FFCWS), a longitudinal cohort of approximately 5000 vulnerable children from 75 US hospitals. The children in this database exhibit many of these identified predictive characteristics, making the database well suited to bivariate and multivariate logistic regression analyses in order to identify correlates with high ED utilization.

In the FFCWS, follow-up interviews covering various topics had occurred 9 years after baseline with the children, their primary caregiver, and their teachers. Flood and colleagues chose asthma and frequent ear infections to represent chronic health problems and defined high ED utilization as 4 or more visits per year. They also assessed history of hospitalization within the previous year, frequency of primary care provider visits, children’s health insurance status, and the primary caregivers’ frequency of ED use.

In total, FFCWS data from 2631 children were included in Flood and colleagues’ analysis. A multivariate model that controlled for the child’s sex, race, household income, and insurance status identified multiple significant variables: a history of child’s hospitalization within the last year, a diagnosis of asthma, the number of office/clinic visits in the past year, the number of primary caregiver ED visits in the past year, having 3 or more ear infections with a year, and insurance status.

Approximately 95% of the study cohort parents had reported that their child had some form of health insurance coverage, and 96% had reported that their child had a usual place for primary care.

The authors note that their analysis has a number of limitations, given that the research was based on social science survey data, with results subject to respondents’ recall bias, for example. Also, the FFCWS population primarily comprised lower-income families, and accurate extrapolation to higher-income families may not be possible. And, the FFCWS only examined the number of ED visits, not the severity of participants’ illness; thus, additional research focusing on the severity of illness is needed to make definitive conclusions.

Nevertheless, the results of this study show that children with a more complex medical history, especially a diagnosis of asthma, are at high risk for ED visits, regardless of socioeconomic factors or insurance status. These findings were consistent with prior studies. The authors conclude that, “By focusing efforts on more aggressive care coordination and management of chronic diseases such as asthma from the first ED visit and educating caregivers on appropriate places of care for their children and themselves, the ED utilization and overall health care spending of children in vulnerable families may be reduced.”

References:

  1. Lee MH, Schuur JD, Zink BJ. Owning the cost of emergency department medicine: beyond 2%. Ann Emerg Med. 2013;62(5):498-505.e3.
  2. Flood C, Sheehan K, Crandall M. Predictors of emergency department utilization among children in vulnerable families. Pediatr Emerg Care. 2017;33(12):765-769.