Primary Care Quality and Subsequent Emergency Department Utilization for Children in Wisconsin Medicaid

doi:10.1016/j.acap.2008.11.004

Academic Pediatrics

Volume 9, Issue 1, January–February 2009, Pages 33-39

https://doi.org/10.1016/j.acap.2008.11.004 Get rights and content

Objective

Children enrolled in Medicaid have disproportionately high emergency department (ED) visit rates. Despite the growing importance of patient reported quality-of-care assessments, little is known about the association between parent-reported quality of primary care and ED utilization for these high-risk children. Our goal was to determine the association between parent-reported primary care quality and subsequent ED utilization for children in Medicaid.

Methods

We studied a retrospective cohort of children enrolled in Wisconsin Medicaid. Parents of children sampled during fall 2002 and fall 2004 completed Consumer Assessment of Healthcare Providers and Systems surveys assessing their child's primary care quality in 3 domains: family centeredness, timeliness, and realized access. Primary outcomes were the rates of subsequent nonurgent and urgent ED visits, extracted from claims data for the year after survey completion. Negative binomial regression was used to determine the association between the domains of care and ED utilization.

Results

A total of 5468 children were included. High-quality family centeredness was associated with a 27% (95% confidence interval [95% CI] 11%–40%) lower nonurgent ED visit rate, but no lowering of the urgent visit rate. High-quality timeliness was associated with 18% (95% CI, 3%–31%) lower nonurgent and 18% (95% CI, 1%–33%) lower urgent visit rates. High-quality realized access was associated with a 27% (95% CI, 8%–43%) lower nonurgent visit rate and a 33% (95% CI, 14%–48%) lower urgent visit rate.

Conclusions

Parent-reported high-quality timeliness, family centeredness, and realized access for a publicly insured child are associated with lower nonurgent ED, with high-quality timeliness and realized access associated with lower urgent ED utilization.

Section snippets

Study Population and Source of Data

This is a retrospective cohort analysis linking the results of cross-sectional CAHPS surveys evaluating quality of primary care to subsequent ED utilization as determined by analysis of administrative Medicaid data.

The study population combines 2 cohorts of children, one cohort from 2002 and the other from 2004. In the fall of 2002 and again in the fall of 2004, the Wisconsin Department of Health and Family Services sent CAHPS surveys to randomly selected enrollees in the Wisconsin Managed Care

Results

A total of 5582 children had completed CAHPS surveys, of which 114 were excluded for incomplete subsequent enrollment. The final cohort of children was very similar in age and gender to the population of all children enrolled in the Managed Care Medicaid program as determined by comparison to enrollment data from the Department of Health and Family Services. Of the 5468 children in the final cohort, 1540 children (28.2%) made a total of 2792 ED visits during the follow-up year, yielding an

Discussion

The study findings indicate that specific domains that comprise high parent-reported quality of primary care for children are associated with lower subsequent nonurgent and urgent visit rates to the ED. High-quality family centeredness, timeliness, and realized access were all associated with lower subsequent nonurgent utilization of the ED for children, while high-quality timeliness and realized access were also associated with a lower subsequent urgent visit rate to the ED.

The findings from

Conclusions

Parent-reported high-quality timeliness, family centeredness, and realized access of primary care for a child are associated with significantly lower rates of subsequent nonurgent ED visits while high-quality realized access and timeliness are also associated with lower rates of urgent ED visits. Whether the ED visits are parent reported or are based on administrative data, the relationship between these domains of care and subsequent utilization is similar, thus strengthening the argument that

Acknowledgments

This work was supported by a grant (K08 HS015482-01A1) to Dr Brousseau from the Agency for Healthcare Research and Quality. The authors report no conflicts of interest or corporate sponsors.

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Non-urgent emergency department (ED) use contributes to healthcare costs and disrupts continuity of care. Factors influencing patient/guardian decision-making in non-urgent situations are poorly understood. We sought to determine the association of patient/guardian – primary care provider (PCP) relationship with non-urgent ED usage and explore related factors.
In an urban practice, we recruited 218 parent-child pairs and administered a survey with the PCP relationship (PDRQ-9), caregiver knowledge of office resources, and care-seeking behavior. We performed a 12-month retrospective chart review to document non-urgent ED visits. We evaluated the association of PDRQ9 and non-urgent ED usage by regression analysis.
Mean child age was 7.0 ± 5 years, and 32.6% of children had at least one non-urgent ED visit. Mean PDRQ9 score was 39.8 ± 7.3 and was not associated with non-urgent ED use (P = .46). Lower child age (P < .001) and shorter time coming to the PCP practice (P < .001) were both associated with increased non-urgent ED use. Only 36.4% reported usually going to their PCP when they are sick. Knowledge of office resources was limited, and when prompted with acute, non-urgent medical scenarios, in 4 of 5 scenarios, 50% or more of participants chose to go to the ED over communicating with or going to their PCP.
We did not find an association between patient-doctor relationship strength and non-urgent ED usage. Many patients/guardians were unaware of the practice's resources and selected the ED as first choice for acute, non-urgent medical scenarios. Additional work is needed to determine interventions to reduce non-urgent ED use.
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We speculate that the discrepancy between these results may be explained by the fact that our rounded approach, combining virologic, patient, and health-system information, enabled more complete adjustment for potential confounding variables in our study, as well as by differences in study cohorts (ie, age groups and indications for ED visits). On the other hand, Brousseau et al evaluated ED visits among Medicaid insured children in Wisconsin.28 Among 5468 children included, 59% of ED visits were classified as nonurgent, and children less than 2 years of age, not having a primary health care provider, having a lower parental education levels, and lower parent-reported quality of care in the OP setting were associated with higher adjusted incidence rate ratios of nonurgent ED visits.
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In a prospective virus surveillance study, infants under 1 year with fever and/or respiratory symptoms were enrolled from outpatient, emergency department, and inpatient settings from December 16, 2019 through April 30, 2020. Demographic and clinical characteristics were collected through parent/guardian interviews, medical chart abstractions, and follow-up surveys. Nasal swabs were collected and tested for viruses using quantitative reverse-transcription polymerase chain reaction.
We enrolled 366 infants and tested nasal swabs on 360 (98%); median age was 6.3 months, 50% male. In total, 295 (82%) had at least 1 virus detected; rhinovirus/enterovirus (RV/EV; 42%), respiratory syncytial virus (RSV; 34%), and influenza (15%) were the most common. RSV was the most frequently detected virus in the inpatient (63%) and emergency department (37%) settings, and RV/EV was most frequently detected virus in the outpatient setting (54%). RSV-positive infants had a lower median age (4.9 months) and were more likely to have respiratory distress, and RV/EV-positive infants were less likely to have respiratory distress. Influenza-positive infants had a higher median age (8 months) and were more likely to have systemic symptoms. RSV infection and younger age were associated with higher odds of hospitalization in multivariable logistic regression.
Across 3 clinical settings, and combining virologic, patient, and health-system information, our results highlight the burden of viral ARI among infants. Overall, RSV, RV/EV, and influenza were most commonly detected, with RSV having the highest disease severity.
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Fifty semistructured interviews were completed with parents who brought their child to the ED for a nonurgent visit (n = 30) and clinic parents (n = 20) with 56% possessing low health literacy. Parents with low health literacy were more inclined to overestimate severity of illness and seek care sooner to gain answers about the illness and treatment options, and visit the clinic only when an appointment was available within hours. Parents with adequate health literacy sought reassurance for their ongoing illness management and valued close relationships with their physician, and were willing to wait longer for an appointment. Fever, vomiting, and young child age prompted some parents to seek expedient care regardless of health literacy.
Caregiving skills (eg, assessing and treating illness, understanding illness severity, and navigating the health care system) in addition to physician-parent relationships and perception of care seem to influence the behavior of parents managing their child's mild acute illness. These factors might be amenable to a future health literacy intervention.
Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid
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To assess the impact of chronic conditions on children's emergency department (ED) use.
Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the “highest” visit rates.
The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees).
The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.
Care coordination for children with sickle cell disease: A longitudinal study of parent perspectives and acute care utilization
2016, American Journal of Preventive Medicine
Citation Excerpt :
Although some encounters may be preventable, others may not be, especially those occurring at off hours. Prior studies have shown limited associations between components of the medical home and acute care utilization.30–32 Second, it is possible that the definition of CC in the NSCH may not be applicable across all populations of children.
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A longitudinal study of 101 children with SCD was conducted. Parents completed a survey instrument on enrollment. Utilization chart review was conducted 9 months post survey. Outcome variables were emergency department encounters and hospitalizations. Independent variables were parent-reported CC, satisfaction with communication between healthcare providers, and satisfaction with communication between healthcare providers and non-medical providers (e.g., schools, child care centers). Multivariate negative binomial regression was conducted to assess associations between CC and acute care utilization. Data were collected in 2011–2013 and analyzed in 2015.
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In light of these latter studies, caution must be exercised when inferring from the meta-analysis data used in the AAP UTI imaging guideline that there is limited clinical benefit to diagnosing and treating VUR in infants and young children. ED utilization is higher among Medicaid patients, and we likewise saw a higher percentage of Medicaid patients in the ED setting compared to our outpatient pediatric urology clinic population (8,9,18). Furthermore, children presenting in the ED setting may be more ill, more likely to require hospitalization, and more likely to have an underlying anatomic abnormality.
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We ascertained imaging and characteristics of children presenting to the Emergency Department (ED) with initial fUTI to determine the impact of patient demographics on admissions for pyelonephritis.
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Emergency Department UsePrimary Care Quality and Subsequent Emergency Department Utilization for Children in Wisconsin Medicaid

Objective

Methods

Results

Conclusions

Section snippets

Study Population and Source of Data

Results

Discussion

Conclusions

Acknowledgments

Am J Emerg Med

Ann Emerg Med

Ambul Pediatr

Jt Comm J Qual Improv

J Pediatr

Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on “The Unraveling Safety Net.”

Acad Emerg Med

Usual source of care and nonurgent emergency department use

Acad Emerg Med

When the visit to the emergency department is medically nonurgent: provider ideologies and patient advice

Qual Health Res

Ambulatory visits to hospital emergency departments. Patterns and reasons for use. 24 Hours in the ED Study Group

JAMA

Quality of primary care and subsequent pediatric emergency department utilization

Pediatrics

Health, United States, 2005 With Chartbook on Trends in the Health of Americans

Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences

JAMA

The impact of outpatient department and emergency room use on costs in the Texas Medicaid Program

Med Care

Emergency room encounters of pediatric patients with asthma: cost comparisons with other treatment settings

J Ambul Care Manage

Emergency medicine versus primary care: a case study of three prevalent, costly, and non-emergent diagnoses at a community teaching hospital

J Health Care Finance

Association of lower continuity of care with greater risk of emergency department use and hospitalization in children

Pediatrics

Measuring hospital quality: what physicians do? How patients fare? Or both?

JAMA

Immunization performance measurement in a changing immunization environment

Pediatrics

Emergency Department Use
Primary Care Quality and Subsequent Emergency Department Utilization for Children in Wisconsin Medicaid