Office “Phone First” Systems Reduce Emergency Department/Urgent Care Utilization by Medicaid-Enrolled Children

BackgroundEmergency department and urgent care (ED/UC) visits for common conditions can be more expensive with less continuity than office care provided by primary care physicians.MethodsWe used quality-improvement methods to enhance telephone triage for pediatric patients by adding additional “Phone First” services including: 1) enhanced office-hours telephone triage and advice with available same-day appointments, 2) follow-up calls to parents of children self-referred to an ED/UC, and 3) parent education to telephone the office for advice prior to seeking acute care. We hypothesized that enhanced office services would reduce ED/UC utilization and cost. We compared changes in ED/UC encounter rates between intervention and regional practices for 4 years (2014–2017) using general linear models, and evaluated balancing measures (after-hour phone calls, acute care phone calls, acute care visits, well child visits) for Medicaid-enrolled and commercially-insured children.ResultsThe study practices dramatically increased office-hours acute care phone triage and advice which correlated with 23.8% to 80.5% (P < 0.001) reductions in ED/UC rates for Medicaid-enrolled children. Office acute care visits decreased modestly. ED/UC visits did not decrease for children in the comparison region. In phone surveys, 94% of parents indicated satisfaction with the ED/UC follow-up call. The decrease in ED/UC visits resulted in an estimated annual cost of care savings for Medicaid-enrolled children in 2017 of $12.61 per member per month which projected to $169 million cost of care savings in Colorado and $6.8 billion in the United States.Conclusion“Phone First” services in pediatric practices during office-hours reduced ED/UC encounters and cost of care for Medicaid-enrolled children.     

Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?

Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.     

Differences in Frequency of Visits to Pediatric Primary Care Practices and Emergency Departments by Body Mass Index

ObjectivesTo examine differences in utilization across health care settings among children by body mass index (BMI) categories to help identify opportunities for interventions.MethodsA retrospective study was conducted using 1 year of electronic health records following an index primary care visit for children 3 to 17 years old in 2016. Index visits occurred at >40 pediatric practices affiliated with a Northeastern health system. Using normal BMI as a reference group, we examined the extent to which children's BMI percentile categories were associated with primary care visits, emergency department (ED) visits, hospitalizations, and ED visit acuity. Age, sex, race/ethnicity, and insurance status were used as covariates.ResultsOf those with biologically plausible values for height and weight (n = 30,352), the prevalences of overweight, obesity, and severe obesity were 16.3%, 12.4%, and 5.7%, respectively. Children outside of the normal BMI range made more primary care visits; however, relative patterns of ED utilization were not consistent. Children with obesity versus normal BMI were less likely to have ED visits of high acuity. Risk of hospitalization was higher among children with overweight or severe obesity.ConclusionsChildren's BMI categories were associated with health care utilization, specifically primary care visits, ED visits, and hospitalizations. Further investigation is needed to explore the drivers of these differences in utilization, such as the impact of stigma and perceived weight bias on care-seeking patterns, and to examine the role of settings outside of primary care in pediatric weight management.     

Telehealth as a Tool for Quality Improvement in the Care of Pediatric Patients in Community Emergency Departments

Nearly 90% of pediatric emergency care is provided in a general emergency department (ED) that serve both adults and children. Many children in the United States do not live near an ED with a high level of pediatric readiness and many children are transferred to dedicated pediatric centers. Telemedicine provides an opportunity to impact care delivery systems to allow for children to be treated closer to home while maintaining high quality care. In this article, we will explore opportunities to use telemedicine in the emergency department and discuss incorporating quality improvement methodology to increase utilization of telehealth services.     

Pediatric patient safety in the prehospital/emergency department setting

The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and high-acuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.     

Urban emergency department utilization by adolescents

This study describes urban emergency department (ED) utilization and follow-up referral patterns among adolescents. ED visits for 14-19-year-old patients at an urban university hospital with adjacent adult and pediatric emergency departments during specified months in 1993 were retrospectively reviewed. A subgroup (n=150) was randomly selected for detailed chart review. One thousand six hundred and thirty-six adolescents were seen in the ED during the study period. Public assistance (n=763; 47%) and commercial insurance (n=480; 29%) were the most common forms of insurance, followed by self-pay (n=357; 22%). The majority of triage codes for ED visits were nonurgent (n=140; 93%). Twenty-five patients (17%) were not referred for follow-up upon ED discharge. Adolescents on public assistance or without insurance may frequently utilize an urban ED for nonurgent medical problems. A group of patients did not identify a primary care provider at triage and were not referred for follow-up. Defining medical problems for which adolescents utilize the ED may help health professionals to tailor community resources to better serve adolescent health care needs.     

"Narrowing the Gap": decreasing emergency department use by children enrolled in the Medicaid program by improving access to primary care

OBJECTIVE: To evaluate the effectiveness of increased primary care access created by North Carolina's Medicaid managed care plan, Carolina Access (CA), in reducing unnecessary emergency department (ED) use in Guilford County. METHODS: Emergency department records of pediatric visits before and after the implementation of CA were analyzed. Variables included patient age, International Classification of Diseases, Ninth Revision discharge diagnosis, insurance status, date of visit, time of visit, and ZIP code. Visits were classified as either urgent or nonurgent based on discharge diagnosis. Rates of ED use per 1000 persons were calculated using county population and Medicaid enrollment figures. RESULTS: A total of 54,742 ED visits occurred between January 1, 1995, and December 31, 1997. Thirty-eight percent of these visits were by children (defined as those aged 0-18 years in this study) enrolled in the Medicaid program. After the implementation of CA, monthly ED rates per 1000 children with Medicaid insurance decreased 24% from 33.5 +/- 5.3 to 25.6 +/- 2.3 (P<.001), which translates to 158 fewer visits per month by children enrolled in the Medicaid program. Nonurgent visits among the population enrolled in the Medicaid program decreased from an average monthly rate per 1000 of 17.9 +/- 3.5 to 11.2 +/- 2.5 after the implementation of CA (P<.001), accounting for most of the decrease in total visits. (All data are given as mean +/- SD.) The rates of total and nonurgent visits among the population not enrolled in the Medicaid program increased slightly. CONCLUSIONS: For children with Medicaid insurance, we found a strong temporal relation between decreased visits to the ED and increased access to primary care services, services that were made available by the implementation of North Carolina's Medicaid managed care plan, CA. Specific services that may be responsible for the decreased ED use include the expanded availability of primary care physicians and the use of telephone triage systems. No similar decrease in ED use was seen among the non-Medicaid-insured group. Arch Pediatr Adolesc Med. 2000;154:791-795     

A model to determine the feasibility of a pediatric practice

A major concern of urban and rural citizens of the United States is the availability of adequate pediatric health care in their community. Community leaders attempting to recruit health care providers and pediatricians considering locating their practice in a specific community need a method by which they can evaluate a community's potential for supporting a new primary care practice. A detailed survey was conducted in early 1988 of pediatric practices geographically dispersed throughout the state of Oklahoma. Data collected from the physicians and their administrative staff reflected the volume of office and hospital visits and practice costs over the prior 12 months. Using the capital costs and direct operating cost data with information obtained on the number of patient visits and revenue generated collected in this survey, we designed a model to project the economic feasibility of establishing a pediatric practice in a specific community. This model can be used to project the number of annual pediatric primary care visits a community can generate, the direct and indirect costs to establish and maintain a clinic, and the gross revenue and net income of the practice.     

Pediatric Quality Improvement Engagement In The Community Setting

Providing safe, high quality care to pediatric patients is a core goal for all healthcare systems. To this end, robust quality improvement and patient safety methodologies have been developed to improve pediatric patient care in academic medical centers. However, given that the majority of pediatric patients are first seen in emergency departments (EDs) in community hospitals rather than academic pediatric medical centers, there is an urgent need to adapt these methodologies to the community ED environment. In this review, we begin to address these issues by looking to successful quality improvement and patient safety initiatives for lessons that can be adapted to the unique challenges and opportunities encountered in community healthcare settings.     

Psychotropic Medication Use in United States Pediatric Emergency Department Visits

Objective and BackgroundLittle is known about pediatric psychotropic medication use in the emergency department (ED), despite a rise in mental and behavioral health visits. This study describes psychotropic medication use in a nationally representative sample of pediatric mental and behavioral health ED visits over a 14-year period.MethodsWe conducted a cross-sectional analysis of pediatric (6–17 years) mental and behavioral health ED visits using the National Hospital Ambulatory Medical Care Survey, 2006–2019. We describe administration of psychotropic medications by medication type, diagnosis, and over time. Using multivariable survey-weighted logistic regression, we examine associations between medication administration and sociodemographics.ResultsA psychotropic medication was administered in 11.4% of the estimated 11,792,860 pediatric mental and behavioral health ED visits in our sample. Benzodiazepines were administered most frequently (4.9% of visits). Visits with anxiety disorders had the highest frequency of psychotropic medication use (26.7%). Visits by Black non-Hispanic patients had a 60% decreased odds of medication administration compared to visits for White non-Hispanic patients. Visits with public compared to private insurance had a 3.5 times increased odds of psychotropic polypharmacy. The proportion of visits in which a psychotropic medication was administered did not change statistically over time.ConclusionsA psychotropic medication was administered in 1 in 10 pediatric mental and behavioral health ED visits. Use differed by sociodemographics but did not change over time. As more youth seek mental and behavioral health care in the ED, we must better understand appropriate medication use to ensure quality and equitable care.     

Unintentional Window Falls in Children and Adolescents

ObjectiveUnintentional window falls represent a preventable source of injury and death in children. Despite major campaigns in some larger cities, there continue to be unintentional falls from windows throughout the United States. We aimed to identify risk factors and trends in unintentional window falls in the pediatric population in a national and regional sample.MethodsA retrospective analysis of annual emergency department (ED) visits from the National Electronic Injury Surveillance System using product codes specific to windows, as well as patient encounters for unintentional window falls from January 2007 to August 2017 using site-specific trauma registries from 10 tertiary care children's hospitals in New England. National and state-specific census population estimates were used to compute rates per 100,000 population.ResultsThere were 38,840 ED visits and 496 regional patients who unintentionally fell from a window across the study period between 0 and 17 years old. The majority of falls occurred in children under the age of 6 and were related to falls from a second story or below. A decreased trend in national ED visits was seen, but no change in rates over time for regional trauma center encounters. A high number of falls was found to occur in smaller cities surrounding metropolitan areas and from single family residences.ConclusionsFalls from windows represent a low proportion of overall types of unintentional sources of injury in children but are a high risk for severe disability. These results provide updated epidemiologic data for targeted intervention programs, as well as raise awareness for continued education and advocacy.     

Potential cost savings of decreased emergency department visits through increased continuity in a pediatric medical home.

PURPOSE: To determine the potential cost savings of decreased emergency department (ED) visits resulting from increased continuity of care provided in a pediatric medical home. METHODS: An economic modeling study comparing the cost of ED visits associated with average continuity of care versus the cost of ED visits associated with a 10% point increase in continuity was performed. This model's premise is that increased continuity will decrease care in the ED. Parameters of the model included average continuity of care and expected use of the ED by pediatric patients as well as the relationship between these two variables. Parameters were estimated from the literature. Average continuity, as measured by the Continuity of Care Index by Bice and Boxerman, was determined to be 40%. Average ED use was estimated to be 0.68 visits/child per year. Continuity of care was stratified into low, medium, and high levels. The Medical University of South Carolina's ED charges were used. An average pediatric practice was estimated to contain 2000 patients. RESULTS: Two hypothetical practices of 2000 patients each were created to represent pediatric medical homes: practice 1 received 40% continuity and practice 2 received 50%. The model's outcome was measured in terms of expected ED charges per practice averted over a 1-year period. Increasing continuity of care by 10% points yielded a decline in expected ED visits from 1362 to 1290 per practice: 19,905 US dollars was saved. CONCLUSION: Continuity of care can yield many benefits, including cost savings from decreased charges associated with less frequent ED use.     

Who is responsible for pediatric triage decisions in Australian emergency departments: a description of the educational and experiential preparation of general and pediatric emergency nurses

BACKGROUND: Pediatric presentations to the emergency department (ED) account for approximately one third of ED presentations. Triage is the process employed by the ED to prioritize presenting patients, including children, on the basis of clinical urgency. This role is undertaken by emergency nurses, and a range of recommendations are available regarding the level of experience and education required by the nurse responsible for pediatric triage decisions. However, little is known about the actual education and experience of nurses undertaking pediatric triage. OBJECTIVES: To describe the level of experiential and educational preparation of emergency nurses responsible for pediatric triage decisions in pediatric and adult and pediatric population EDs. METHODS: An anonymous survey of emergency nurses responsible for pediatric triage decisions in a number of specialist and mixed EDs was conducted. RESULTS: Education and experience varies widely among nurses responsible for pediatric triage decisions. Many nurses practicing pediatric triage do not meet recognized guidelines for the levels of education and experience required to undertake pediatric triage. Nurses practicing in mixed population EDs were less likely to meet the recommended educational requirements than pediatric emergency nurses and yet reported no difference in their level of confidence in undertaking pediatric triage. CONCLUSIONS: Educationalists and managers must make a commitment to pediatric triage preparation for nurses in EDs providing pediatric services. In particular, emphasis must be placed on providing pediatric continuing education for nurses practicing in mixed population EDs. However, it is also essential that the impact of education and experience on patient outcomes be investigated before an attempt is made to influence the preparation of nurses for triage.     

Pediatric Asthma in the Community Emergency Department: Room for Improvement and Aligned Incentives

Asthma is a common reason for emergency department (ED) visits in children. Over 80% of children who visit an ED go to a general, not a pediatric-specific, ED. The treatment children with asthma receive in general EDs is not as compliant with national guidelines as is treatment in pediatric-specific centers. Several studies document improvements in pediatric asthma care through quality improvement initiatives, but few address the emergency care of pediatric asthma in the community setting. National programs such as Pathways for Improving Pediatric Asthma and Translating Emergency Knowledge for Kids provide resources to community EDs for improving pediatric asthma care. More research is needed to determine if programs such as these, as well as partnerships at the local level, can have a positive impact on the emergency care of pediatric asthma. It is essential that we bridge the gaps in care between community and pediatric-specific EDs to improve the quality of emergency care for the over 7 million children in the US with asthma.     

Sexual and Gender Minority Adolescents: Meeting the Needs of Our LGBTQ Patients and Their Families

Adolescent patients comprise up to 16% of all emergency department (ED) visits in the United States. Although an exact prevalence is difficult to determine, an estimated 4-17% of youth identify as lesbian, gay, bisexual, transgender, and questioning. Health care providers need to understand gender identity and sexual orientation to provide competent medical care within a clinical setting that is safe for minority youth. Despite the ED presence of lesbian, gay, bisexual, transgender, and questioning teens, many ED providers report a lack of comfort with understanding the health care needs of this patient population. In this article, we aim to review the topics of gender identity, gender presentation, sexual orientation, and pronoun use, and provide practical guidelines for eliciting important information in the care of sexual and gender minority youth.     

Over the rainbow: advancing child health in the new millennium.

Research studies presented at the annual Pediatric Academic Societies meeting provide continued evidence of the impact of the environment on child health, the prevalence of mental health problems in children and adolescents, and the benefits of comprehensive health care coverage. Other studies report on the efficacy of new formats for delivering pediatric health care and the content of health supervision visits, and identify potential solutions for existing deficits and disparities in health care delivery. Despite this abundance of positive studies, the United States continues to lag behind many developed countries in its broader adoption of effective strategies such as universal health coverage. Child health care professionals must continue to speak out on behalf of the needs of infants, children, and adolescents and work for systemic change in health care delivery.     

Adolescents who use the emergency department as their usual source of care

OBJECTIVE: To examine the factors associated with use of the emergency department (ED) as the only source of health care among adolescents. DESIGN: Analyses of the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, a nationally representative sample of 6748 in-school male and female adolescents in 5th through 12th grade. The X2 statistics and logistic regression analyses were computed with the use of SUDAAN. RESULTS: Overall, 4.6% of the adolescents in the survey, or 1.5 million adolescents in the United States, reported that the ED was their usual source of health care. In multivariate models, factors associated with the use of the ED included male sex, African American ethnicity, fewer financial resources, and living in a rural area. Adolescents with higher levels of risky behaviors, a history of physical or sexual abuse, and higher depression scores were all more likely to use the ED as their usual source of care. Adolescents who reported using the ED as their usual care source were also less likely to have had regular well visits and were more likely to report having missed needed care than those with other sources of primary care. CONCLUSIONS: Adolescents who use the ED as their usual source of care are often from vulnerable populations. Many have special mental or physical needs that are unlikely to be met with ED visits only, and they are likely to have missed care they needed. Creating linkages between EDs and other services could help at-risk adolescents identify and use more appropriate sources of primary care.     

Rethinking pediatric trauma triage

Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide.  Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources.  This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.     

Personnel costs and perceived benefit of telephone care in the management of children with type 1 diabetes

Intensive management of patients with type 1 diabetes improves control and reduces rates of long-term complications. Telephone care as an adjunct to office visits is important in the management of children with type 1 diabetes in pediatric endocrine practices in the USA. The goal of this project was to assess the personnel costs and patients' perceptions of telephone care in a moderately sized pediatric diabetes care center (301 patients with a diagnosis of type 1 diabetes). There were two parts to this study. First, telephone logs were kept by three pediatric endocrine nurses (2.2 full-time equivalents [FTEs]) and three pediatric endocrinologists (2.0 FTEs) for two 1-wk blocks. Computerized databases were used to determine the number of clinic visits in 1998. Second, a survey assessing the frequency, perceived value and consequences of phone contact with the diabetes team was distributed to 40 families at clinic visits. Mean nurse/certified diabetes educator (CDE) time spent on the phone was 12.1 h/wk, with an additional 9.7 h/wk spent preparing and documenting. Physicians spent 6.4 h/wk on the phone, and 6.1 h/wk preparing/supervising/documenting. For our 301 patients with diabetes, the weekly personnel cost for telephone care at our institution was 1367 US dollars or 236 US dollars/patient/yr. Of the families surveyed, 80% reported that they had used the phone to obtain care for their child with diabetes and 55% had paged the doctor on call in the previous 6 months. Seven patients reported that phone contact prevented a total of 13 emergency department (ED) visits and 35 office visits. Using a cost estimate of 550 US dollars per ED visit, and 103 US dollars per office visit, the cost of prevented visits was 232 US dollars/patient/yr in our center. These data indicate that telephone care is effective in reducing the cost of reimbursable care via the ED and office visits, as well as avoiding hospitalization. However, the cost of providing this telephone care is not reimbursable to providers.     

Effect of Using Pediatric Emergency Department Virtual Observation on Inpatient Admissions and Lengths of Stay

ObjectiveTo determine whether using emergency department (ED) virtual observation for select pediatric conditions decreases admission rates for these conditions, and to examine effects on length of stay.MethodsThe option of ED virtual observation care for 9 common pediatric conditions was introduced in 2009; associated order sets were developed. Retrospective secondary analyses of administrative data from our tertiary care pediatric ED and children's hospital were performed for the year before (year 0) and after (year 1) this disposition option was introduced. The proportion of visits admitted to the inpatient unit and length of stay (LOS) were determined for all visits considered eligible for ED virtual observation care on the basis of diagnosis codes for both study years.ResultsThere were 1614 observation-eligible visits in year 0 and 1510 in year 1. In year 1, 18% (n = 266) of observation-eligible visits received ED virtual observation care. Admission rates for observation-eligible visits were similar after this model of care was introduced (25% year 0, 29% year 1, P = .02). Median LOS for ED virtual observation visits was 8.8 hours (interquartile range 6.5–12.4). ED LOS was shorter for ED discharges (5.6 hours year 0, 5.1 hours year 1, P < .001) and unchanged for admissions (6.0 hours year 0, 5.8 hours, year 1, P = .41) after introducing ED virtual observation.ConclusionsAdmission rates for observation-eligible visits were not lower in the year after ED virtual observation care was introduced. LOS decreased for ED discharges and was unchanged for admissions. Reevaluation of the effects of pediatric ED virtual observation on admission rates and LOS after longer periods of use is indicated.