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Factors Associated With Emergency Department Utilization for Nonurgent Pediatric Problems
Kevin Phelps, DO;
Christine Taylor, PhD;
Sanford Kimmel, MD;
Rollin Nagel, PhD;
William Klein, MD;
Sandra Puczynski, PhD
Arch Fam Med. 2000;9:1086-1092.
ABSTRACT
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Objective To identify specific caretaker and utilization characteristics predictive of the use of the emergency departments (EDs) for nonurgent reasons. Each year more than 20 million children in the United States seek medical care in EDs. Between one third and one half of these visits are for nonurgent reasons.
Design A descriptive study conducted during a 6-month period.
Setting Two urban hospital EDs.
Measure A questionnaire was designed to elicit information about specific caretaker characteristics and their reasons for using the ED for their child's nonurgent medical care.
Subjects Two hundred caretakers and children brought to the ED for nonacute medical care. Caretakers in this study included mothers (82%) with a mean age of 30 years, single caretakers (70%), and unemployed caretakers (60%). The average age of the children was 6.2 years.
Results Most caretakers (92%) reported having a continuity physician for their children. Caretakers who reported being taken to the ED when they were children (P<.002) and those with Medicaid insurance (P<.001) were more likely to view the ED as the usual site of care. Being a single parent was a predictor for nonurgent visits (P<.05).
Conclusions Predicting which caretakers are at risk for using the ED for nonurgent care when their children are sick provides the primary care physician a means of identifying specific patients who may benefit from interventions designed to promote a more cost-effective approach to using medical resources.
INTRODUCTION
EACH YEAR, more than 20 million children in the United States seek medical care in emergency departments (EDs). In fact, 1 in every 4 ED visits involves a child.1-3 Studies indicate that between one third and one half of these visits are for nonurgent conditions.3-4 This type of medical service utilization effects the cost and quality of health care in several ways. Primary care physicians (PCPs) provide prospective, comprehensive, continuous care for the majority of annual pediatric visits in the United States.5 Visits to the ED for nonurgent conditions that could be managed by PCPs in their offices are missed opportunities for providing preventive and essential child health care. Primary care physicians are better positioned than ED physicians, by nature of their training and the setting in which they practice, to assist their pediatric patients in the context of the child's medical history, previous responses to treatment, family issues, rapport, and compliance. The PCP provides the necessary follow-up and preventive care, including immunizations and anticipatory guidance, that is important for all children.
Emergency department utilization by caretakers for nonurgent reasons contributes to the escalating financial costs in the US health care system. Medical care provided in the ED can be significantly more expensive than care provided by office-based PCPs. While the issue of the true cost of care vs charges is a complex one that is being debated currently, it seems that charges for the same services are higher in the ED. For example, the charge to a patient who visits one of the study hospital's EDs for what is considered to be a nonurgent visit (eg, otitis media) is approximately $170. The same patient would be charged approximately $55 for an office visit with a family physician at a family practice center.
Studies have reported associations between parental characteristics and use of the ED for nonurgent reasons.5-7 These studies have unanimously reported that this type of ED utilization is associated with a lower socioeconomic status. However, few studies have identified the myriad of possible factors that contribute to this phenomenon. If we as family physicians are to effect change in caretaker utilization of EDs for their children, then it is important that we determine the caretaker's characteristics and reasons for using the ED (rather than the PCP office).
Recent studies have suggested that educational efforts can have an effect on caretakers' health-care use behaviors. Efforts to educate caretakers about common health problems in children (eg, fever education) have been shown to be effective in reducing the number of visits to health care providers.8 Characteristics of the "at-risk" population must be known if PCPs wish to target specific interventions to this group. Therefore, the purpose of this study was to identify specific caretaker and utilization characteristics that are predictive of the use of the ED for nonurgent care. The following research questions were examined: (1) Will specific caretaker and health care utilization characteristics be significantly associated with the site of routine pediatric care when a caretaker reports their child as sick? (2) Will these characteristics be significantly associated with pediatric visits categorized as nonurgent by qualified medical personnel? (3) Are caretakers who received the majority of their own childhood care at ED facilities more likely to take their children to the ED for nonurgent medical care? (4) Are caretakers who do not identify with a particular PCP more likely to use EDs when their children are sick?
SUBJECTS AND METHODS
SAMPLE
The study sample consisted of 200 caretakers who brought their children to 1 of 2 urban hospital EDs in a large Midwestern city. A caretaker was defined as a parent, legal guardian, or individual who has the primary responsibility for the child's ongoing care. Children included in this study were younger than 16 years. Hospital A was a 300-bed medical college hospital, and hospital B was a 200-bed hospital located in the inner city. Both hospitals serve a mixed patient base that includes a large population of people who receive Medicaid. The study subjects (the caretakers) were approached and asked to complete a survey. Institutional review board approval was obtained for this study.
INSTRUMENT
The survey instrument consisted of 11 forced-choice questions, 1 open-ended question, and a short demographic section. Questions focused on the "suspected correlates" of "pediatric overuse" of EDs, including the relationship of the caretaker to the child, educational attainment of caretakers, family type, employment status, transportation availability, insurance type, payment requirement at their physician's office, caretaker age, and whether the family currently had a "regular doctor." In addition, caretakers were asked about their reasons for bringing their child to the ED on this occasion, their usual site of medical care when their child is sick, and where they (the caretakers) were taken for medical care when they were children. These variables were chosen from the literature and the authors' specific hypothesis about the potential power of modeling in predicting behavior.3, 6-7
The survey was piloted in the ED of hospital A and reviewed by physician representatives from the ED and the Department of Family Medicine, Medical College of Ohio, Toledo. The questionnaire was analyzed using the Fry Readability Scale and was estimated to be at the sixth-grade level.9
PROCEDURE
Three medical school students were trained to distribute and collect the surveys at each of the sites. Because characteristics of the caretakers had the potential to vary based on the day of the week and the time of day that the child was brought to the ED (eg, working parents vs nonworking parents), a schedule was designed so that weekday, weekend, daytime, and evening shifts were sampled in 4- to 6-hour blocks at each study site. In addition, data were collected during both a summer block and a winter block to avoid any seasonal bias.
The medical school students approached all caretakers of pediatric patients after they had completed the ED registration process. After describing the purpose of the study, the medical students ascertained caretaker eligibility, recorded the patient's name on a separate form coded to the questionnaire number, answered any questions, and distributed and collected the questionnaires. Caretakers of children requiring immediate medical or surgical attention were not approached for participation. Following each shift, the medical student reviewed the patients' ED records and documented the presenting complaint, vital signs, diagnosis, and insurance type on a coded form.
To obtain the most accurate measure of the status of the visit, 2 physicians, 1 family physician and 1 double-boarded pediatrician–family physician reviewed data collected on the coded form (age and sex of the child, health complaint, vital signs, and discharge or admitting diagnosis) and rated the encounter as either an urgent or a nonurgent problem. An urgent problem was defined as "a medical condition or injury for which a delay of diagnosis or treatment for 24 hours would increase the likelihood of an adverse outcome."10-11 This protocol was used to identify characteristics of the caregiver that might predict the use of the ED for nonurgent care. This was also the evaluation procedure used by a major managed care organization in our area to audit records. Each physician reviewed 20 cases and met to review and refine their understanding of the coding policy. After a second coding meeting, the physicians independently rated all 200 cases.
STATISTICAL ANALYSIS
Agreement between physicians in rating the encounter as urgent vs nonurgent was expressed as a  statistic.12 Scores greater than .80 suggest excellent agreement between the 2 raters.13 Descriptive statistics were used to report group characteristics. Multiple logistic regression analyses (using the backward-step method employing the  2 statistic) were computed to assess the independent effects of specific caretaker characteristics with status of visit and site of usual medical care when the child is sick as the dependent measures. Responses to the open-ended questions were sorted into like categories and reported as percentages of the total number of respondents.
Many of the independent variables were entered into the logistic regression analyses as indicator variables; that is, representing the presence or absence of the characteristic.14 When more than 2 levels of response were possible, as in "caretaker education," 1 level, in this case, "less than 12 years of schooling," was used as the reference group for both other levels (high school graduates and those who attended college). The level of significance for the analyses was set at P<.05.
RESULTS
A total of 200 caretakers and children were admitted to the ED at 1 of the 2 study hospitals (125 at hospital A and 75 at hospital B). Since caretaker and pediatric patient characteristics for the 2 sites were similar when matched for caretaker age, educational attainment, type of family unit, employment status and type of insurance, and child's age and sex, the data were combined and treated as 1 data set.
Overall, caretakers were young (mean ± SD age, 30 ± 9.4 years) and predominately mothers (82%). Approximately 30% of the caretakers lived in intact family units, defined as married with both parents living in the home. Only 27% of the caretakers were employed full-time, and 60% were unemployed. Seventy-six percent of the caretakers had a high school diploma and 42% had at least "some college." The mean ± SD age of the children seeking care was 6.2 ± 4.7 years. Table 1 summarizes the demographic characteristics of the caretakers and children.
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Table 1. Demographic Characteristics of Caretakers and Children
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Ninety-two percent of the caretakers reported that their child had a "regular" family physician or pediatrician. Sixty-nine percent indicated that the same physician had followed their child for 2 years or more. When asked where they usually took their children for care when they were sick, 75% responded that they usually took their children to the "family doctor's office." The other 25% reported that they usually took their children to either an urgent care physician or ED. The review of the child's medical record after the visit revealed that 54% were covered for medical insurance by Medicaid, 37% had private or commercial insurance, and 9% reported having no insurance. Seventeen percent of the caretakers reported being required to pay at least a portion of the physician's fee when taking their child to their private physician.
SITE OF USUAL MEDICAL CARE WHEN CHILD IS SICK
A logistic regression analysis was done to examine the relationship between the site of usual care and study variables. "Relationship to the child" and "whether or not the child had a regular doctor" were excluded from further analyses due to lack of variability in this sample. Complete data for all variables of interest were available for 157 of the subjects. The remaining analyses were conducted on these subjects.
When all 8 of the remaining variables were entered into the logistic regression, 2 variables, insurance type (22 = 13.28, P<.002) and "modeling effect variable" (21 = 21.21, P<.001) were significant predictors for "using ED as the site of usual medical care when child is sick." When compared with the patients receiving Medicaid, caretakers reporting "no insurance" (odds ratio [OR] = .08) and "commercial insurance" (OR = .27) were less likely to report "using an ED as the site of usual medical care when child is sick" for their child. Caretakers who recalled being taken to EDs for their usual childhood care were more likely to take their own children to EDs for care when their child is sick (OR = 7.18). These 2 variables successfully predicted 125 (79.6%) of 157 of the instances of variation in the "site of usual medical care when child is sick" variable. Table 2 summarizes the predictors for the "site of usual care when child is sick" dependent variable.
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Table 2. Caretaker Characteristics Associated With the Site of Usual Medical Care for Their Sick Children*
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STATUS OF VISIT
The 2 physicians independently rating each encounter as urgent vs nonurgent agreed 98% of the time ( = .96). The encounters with divergent ratings (n = 4) were excluded from further analysis. The physician raters classified 65% of the visits to the EDs as nonurgent. The rate was virtually identical (64.3%) for the subset of subjects for whom all data was complete (n = 157). The most common problems rated as urgent were trauma/injuries (63%) and infections (27%). Examples of the trauma/injury category included lacerations, animal bites, burns, and head injuries, while examples of infections categorized as urgent were complicated otitis media, central nervous system infections, and lower respiratory tract infections. Conditions categorized as nonurgent also fell into these 2 categories but in reverse proportion, with 49% of the nonurgent conditions from infections, 30% from trauma/injuries, and 10% from rashes. Examples of the infections category included upper respiratory tract infections, skin lesions, and gastritis, while examples of trauma/injury categorized as nonurgent were abrasions, contusions, and sprains and strains.
The second analysis explored the relationship of the variable "status of visit" with the same 8 variables with "site of usual medical care when child is sick" as an additional independent variable. When all 9 variables were entered into the logistic regression, only 1 variable, "type of family unit," was significant (22 = 6.84, P < .04). Using "married with both parents at home" as the reference group, both the "single with no adults" group (OR = 2.33) and the "single with other adults" group (OR = 2.86) were more likely to have the child's visit rated as nonurgent. The "type of family unit" variable alone successfully predicted 79.4% of the nonurgent visits.
CARETAKERS' REASONS FOR TAKING THEIR CHILD TO THE ED
Caretakers were asked the reasons why they brought their child to the ED on this occasion. Subjects were given 8 choices and an option to write any additional reasons. Caretakers were told to choose as many options as appropriate. The most common reason stated was that the "doctor's office was closed" with 46% of the caretakers choosing this response. Of the 8 response choices presented to caretakers as common possible reasons for bringing their child to the ED, only "my child is so sick that he/she required immediate care" is considered a valid reason for bringing a child to the ED. Only 70 caretakers (35%) chose this option. Of this subset, only 19 reported attempting to contact their physician. Table 3 summarizes these responses.
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Table 3. Caretakers Reasons for Bringing Child to the ED*
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Twenty caretakers wrote in additional reasons for bringing their child to the ED that were not symptom related. The responses varied, and included "no established doctor"; a group of referral responses that included nurse, coach, and urgent-care staff referrals; a group of time-related responses, such as "in a hurry," "I work here . . . it's quicker," and "can't wait to get an appointment"; and finally, a group of "doctor satisfaction" responses that included "my doctor is not concerned" and "I don't like my current doctor."
COMMENT
In the past, much has been written about the population receiving Medicaid and their tendency to overuse EDs for themselves and their children.15-18 Strategies have been established to influence these usage patterns with limited success; however, strategies that only address demographic patterns and do not address supporting causes seem to be destined for failure. For example, patients covered by state Medicaid programs incur no financial penalties as a result of their decision to use a more expensive form of medical care. Some states have addressed this issue by allowing managed care organizations to administer insurance products to the sector of patients receiving Medicaid. Managed care plans, as a rule, advocate patient education, health promotion, and disease prevention by encouraging members to visit their PCPs on a regular basis. These "routine" visits provide an opportunity for patients and physicians to build a relationship with the hope of arriving at a common understanding regarding appropriate use of medical resources, and providing better medical care. Some studies show that this approach to increase care by PCPs can lead to decreased ED usage.19-20 However, a study describing the effect of implementing managed care (including assigning PCPs) into the population receiving Medicaid increased both the level of primary care and ED usage.21 This is in agreement with our finding that despite more than 90% of the patients in this study having a PCP for at least 2 years, there was still a large number of unnecessary ED visits. The implication is that it may not be sufficient to simply supply a patient with the name of a PCP, and that other factors interfere with appropriate ED usage.
It has been assumed that caretakers who use the ED as the site of routine medical care when their children are sick would have higher rates of nonurgent ED usage. In our study, "role modeling" proved to be a strong predictor for the subset of caretakers who reported choosing the ED as the site of routine sick care for their child. It may partly explain why patients with Medicaid, even after being assigned a PCP, continue to choose the ED as the source of medical care for their children. This may have been the case in the Maryland Medicaid findings.21 Certainly, the power of role modeling (parent to child) has been established in the literature across many settings by Nebor (unpublished data, 1986, retrievable from ERIC Document Reproduction Service, ED 286 150, Report CS 008 910) and Onestak et al.22 In this case, a young parent without the support of another adult may revert to familiar patterns when encountering the stress of dealing with a sick child. A surprising finding of our study was that the patients who sought their routine sick care at an ED were no more likely to have nonurgent reasons for their visit than those who sought routine sick care elsewhere. However, it is harder to rule out modeling of nonurgent ED usage affecting the decision-making of the caretaker, so interventions to break the cycle of modeled behavior may still provide some benefit.
Consistent with previous reports,3-4,10 almost two thirds of the visits to the ED in this study were classified as nonurgent by qualified medical personnel. The only variable that proved predictive of nonurgent visits was a caretaker who was single and had no other adults living in the home. The interplay that adult couples have when evaluating a sick child and ultimately deciding when and where medical services are necessary may be absent in the single-parent household. This finding, corroborated by other studies,8, 23 also suggests that single caretakers may benefit from educational programs that teach them how to recognize and manage minor illnesses at home. Conversely, a recent study indicated that an extensive education and support program for clients receiving Medicaid failed to reduce nonurgent ED use.24 Information derived from this study could be used to identify caretakers at highest risk for nonurgent ED use based on the answers to a few questions at the time of enrollment into a health plan or by the state Medicaid bureau. This would allow a more targeted and potentially more extensive and longitudinal intervention to a smaller identified at-risk population.
Telephone triage and support systems have been recommended as effective methods of gatekeeping by health care professionals to reduce nonurgent ED use.25-26 Interestingly, referral by the PCP did not lead to a significantly lower rate of nonurgent visits to EDs in this study. Caretakers had specific reasons for utilizing the ED for their children's health complaints. Nearly half of the caretakers reported that they brought their children to the ED because their physician's offices were closed. Other frequently quoted reasons included, "my child is seen more quickly in the ED," "I don't know how to reach my doctor when the office is closed," and "I tried, but could not reach my doctor over the phone." These comments suggest that there is a perceived and/or true lack of physician accessibility, and possibly a lack of understanding of how to appropriately proceed when their physician is not available. These represent areas in which physicians could increase their accessibility to caretakers after hours, thereby reducing nonurgent ED usage.
Coupled with the apparent lack of physician accessibility, are the perceptions of caretakers regarding the severity of their child's illness. Previous studies have demonstrated that parents tend to overestimate the severity of their child's illness and as a result may feel justified in taking their children to the ED.11, 23, 27-29 In this study, more than a third of caretakers viewed their child as requiring immediate care. Although these children were young, they were not more likely to have an illness that was determined by physicians to require urgent attention. A previous study showed that children of nurses do not have lower nonurgent ED usage, which suggests that ED overuse may not be entirely corrected by patient education. However, physicians could provide better anticipatory guidance for caretakers in determining when severity of their child's illness requires an ED visit.
Limitations to this study include the relatively small sample of caretakers taken from 1 urban city. This may limit generalizability of the findings and reduce the power to discern associations. The data collection also occurred during limited study periods during the summer and winter months, and as a result, represents a snapshot of data rather than data collected for longer intervals, which may be more representative over time. In addition, the definition of what is a reasonable reason to seek ED care has changed since this study began. Recently, there has been an increasing drive to define appropriateness of ED use based on what a prudent layperson would determine appropriate. While this is an important change in the definition, especially in terms of physician gatekeeping, our study results provide important suggestions that may decrease ED usage for nonurgent medical care.
This study was designed to identify characteristics of the caregiver that would predict the use of the ED for nonurgent care. To answer this question, we needed the most accurate categorization of the child's illness. We followed the evaluation procedure used by a major managed care organization in our area (Northwest Ohio) to audit records. This strategy included the use of the "diagnosis" in determining urgent vs nonurgent care. This strategy was not intended to identify characteristics in the patient that would assist health care providers to triage more effectively.
Knowing which caretaker characteristics are predictive of ED use for nonurgent medical care provides some guidance for designing and targeting intervention strategies. Self-care manuals and programs that educate caretakers about recognizing and managing common, nonurgent medical conditions at home is one strategy, although this may provide only limited returns based on recent studies. A telephone triage and advice system could serve as an additional resource for caretakers having difficulty managing their child's illness at home.30 Promoting greater reliance on the primary care physician and expanding physician accessibility would likely reduce ED usage for nonurgent medical care.
AUTHOR INFORMATION
Accepted for publication September 11, 2000.
Funding for this study was provided by the Medical College of Ohio's Quality Health Care Initiative Program, Toledo, and the Ohio Academy of Family Physicians' Foundation, Columbus.
We would like to acknowledge the data collection efforts of Karen Grasse, Luke Ragan, and Raj Narayan, all medical students at the Medical College of Ohio.
Corresponding author and reprints: Kevin Phelps, DO, Department of Family Medicine, Medical College of Ohio, 1015 Garden Lake Pkwy, Toledo, OH 43614 (e-mail: kphelps{at}mco.edu).
From the Department of Family Medicine, Medical College of Ohio, Toledo. Dr Klein is currently a fellow in sports medicine at Providence Hospital, Southfield, Mich.
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