Chronic medical conditions linked to high emergency department use

1. Of children with baseline high emergency department (ED) use, defined as ≥4 ED visits in one year, only 16% experienced sustained high ED use (≥8 ED visits) over the following 2 years.

2. Children with initial baseline high ED use and sustained high ED use tended to be adolescents, white, female gender, and have ≥1 chronic medical conditions.

Evidence Rating: 2 (Good)

Study Rundown: Children account for over one-quarter of ED visits in the United States, with Medicaid-insured children forming a greater proportion of those visits than privately insured children. However, data on the characteristics of ED use of children with high baseline ED usage is lacking in current pediatric literature. In this study, researchers evaluated a cohort of Medicaid-insured pediatric patients through the MarketScan Medicaid Database to describe their trend in ED use over time as well as the demographic and clinical characteristics of children with sustained high levels of ED use. Researchers found that approximately 8.5% of the cohort experienced “high ED use,” or ≥4 ED visits during the index year. Of this high ED use group, approximately 16% experienced “sustained high ED” of ≥8 ED visits over the next 2 years. In contrast, children who had non-high ED use or no ED use during the index year had rates of sustained high ED use of 4.3% and 0.2% over the following 2 years. Patients with high ED use followed by sustained high ED use tended to be adolescents, white, and female and had greater odds of having ≥1 chronic medical conditions. Limitations of this study included reliance on billing codes, which may not accurately reflect disease prevalence, and limited generalizability due to the MarketScan Medicaid Database not permitting state-level identification. Overall, this data suggests that the majority of children with high ED use will not go on to sustain such high ED use. However, children with chronic medical conditions – particularly those with multiple chronic conditions – have a greater odds of sustaining high ED use. As such, the authors advocate for further research on interventions such as targeted outpatient interventions like the use of the patient-centered medical home for this high risk group.

Click to read the study, published today in Pediatrics

Relevant Reading: Recurrent and high-frequency use of the emergency department by pediatric patients 

In-Depth [retrospective cohort]: This 3-year retrospective cohort study included a total of 470 449 children between ages 1-16 years, who experienced at least 1 ED visit (not resulting in admission or death) and who were enrolled in Medicaid or the Children’s Health Insurance Program from 2011 to 2014. In the index year (Jan 1, 2012 to Dec 31, 2012), researchers identified 39 345 (8.5%) children with high ED use. The primary outcome of the study was sustained high ED use or ≥8 ED visits in 2013-2014. Of the children with initial high ED use, approximately 16% experienced sustained high ED use over the following two years. For non-high ED users or children with no ED use, sustained high ED use throughout 2013 and 2014 was 4.3% and 0.2%, respectively. The most common ED complaints for children with sustained high ED use were respiratory diseases (16.0%), sinus or upper respiratory tract infections (14.7%), and asthma (13.8%). Secondary outcomes included patient demographics and number of chronic conditions. Children with high ED use in 2012 who sustained high ED use in the following 2 years were more likely to be older or 12-16 years of age (adjusted odds ratio [aOR]=1.4; 95%CI=1.27-1.50), white (reference group) and female (reference group), compared to children without sustained high ED use. Chronic conditions were identified using the Agency for Healthcare Research and Quality’s Chronic Condition Indicator, an algorithm that categorizes ICD-9 diagnosis codes as chronic or non-chronic. High ED users compared with non-high ED users in 2012 had higher prevalence of chronic conditions (75.5% vs. 64.7%) and multiple chronic conditions (51.1% vs 37.9%). The number of chronic conditions increased the odds of sustaining high ED use (aOR=1.3 and 95%CI=1.18-1.41 for 1 chronic condition; aOR=1.6 and 95%CI=1.43-1.73 for 2 conditions; and aOR=2.1 and 95%CI= 1.89-2.25 for ≥3 conditions).

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