Frequent emergency department use in the paediatric population: A systematic literature review

Abstract

Objective We systematically reviewed the literature on paediatric frequent emergency department (ED) users to identify and to synthesize characteristics and factors associated with frequent ED utilization among this population in the United States. Methods We searched Medline (Ovid), CINAHL (Ebsco), and Embase (Ovid) to identify all relevant studies after 1990. We focused on US studies analysing paediatric frequent ED (PFED) users excluding those focused on specific subgroups. Two reviewers independently selected articles and extracted data on predisposing, enabling, behavioural, need and reinforcing factors. Results Fifteen studies met the inclusion criteria. PFED users comprised 3% to 14% of all paediatric ED users and accounted for 9% to 42% of all paediatric ED visits in 11 studies that defined frequent use as four to six ED visits per year. Most PFED users were less than 5 years old who had public insurance coverage and a regular provider. Public insurance compared to private residency in disadvantaged areas, having at least one chronic or complex condition and a history of hospitalization, were associated with frequent use. Children who had a regular primary care provider were less likely to exhibit frequent ED use. Conclusions Minimizing unnecessary ED visits by frequent utilizers is a quality improvement and cost‐saving priority for health systems. Our findings indicate that many PFED users have greater healthcare needs and face barriers accessing care in a timely manner, even though some have regular providers. To better address the needs of this vulnerable group, health systems should focus on educating caregivers and expanding access to providers in other settings.

Examining frequent emergency department use among children and adolescents with autism spectrum disorder

“…Our analysis also includes the Elixhauser comorbidity index where patients are categorized as having zero, one, or two or more comorbidities across all ED visits to control for disease complexity. In addition, we account for multiple diagnoses for conditions commonly associated with both ASD and ED use by children and adolescents in the literature (Deavenport-Saman et al, 2016;Giannouchos et al, 2020;Simonoff et al, 2008). These conditions were defined using ICD-9 and ICD-10 codes in both primary and secondary diagnoses as dichotomous measures indicating whether a patient had at least one ED visit falling within each category, namely, attention-deficit/hyperactivity disorder (ADHD), epilepsy, depression, anxiety, headache, asthma, upper respiratory infection, otitis, viral infection, fever, pharyngitis, gastroenteritis and colitis, urinary tract infection, abdominal pain, injuries, vomiting, and intellectual disability.…”

“…In addition, prior work has not fully explored frequent ED use in this population, with Vohra and colleagues pointing at the need to examine frequent ED use in individuals with ASD (Vohra et al, 2016). Frequent ED use (⩾4 ED visits per year) in children and adolescents has commonly been associated with complex and special healthcare needs and multiple comorbidities (Giannouchos et al, 2020). Thus, there is reason to believe that children and adolescents with ASD might be more likely to exhibit frequent ED use compared to those without ASD.…”

Health insurance, pediatric asthma, and emergency department usage

“…State insurance is a proxy for poverty, and neighborhood concentrations of publicly insured children and high poverty often represent the same places (Alcala et al., 2017; Gold et al., 2012). Although the ACA decreases barriers to insurance covered primary care, socioeconomically challenged communities that lack adequate providers and healthcare services use the ED as a care option (Chang et al., 2014), as noted in a previous literature review (Giannouchos et al., 2020). Local shortage of primary care providers, and patient distance from healthcare sites that accept state insurance, are barriers to health care (Alcala et al., 2017; Chang et al., 2014; Garthwaite et al., 2017).…”

“…In addition to public health insurance status, ethnic minority status is a determinant of increased ED use (Alpern et al., 2014; Giannouchos et al., 2020; Pinto et al., 2020). African American and Black asthmatic children are most commonly noted as likely to utilize an ED (Eum et al., 2019; Herndon et al., 2012; Malhotra et al., 2014).…”

Pediatric high users of Canadian hospitals and emergency departments

“…For example, the cohort identified 591 (0.13%) patients with only one or two ED visits for a four-year period as a most frequent user. To remove these inappropriate cases, we restricted our high user group to patients who both met the Dynamic Cohort’s definition of a frequent ED user and had at least 3 ED visits over the four-year period [ 5 ].…”