Trends in Regionalization of Emergency Care for Common Pediatric Conditions

Abstract

Background: For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis.

Methods: We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes.

Results: Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings.

Conclusions: Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions.

Figure 1:

Trends in referral rate for asthma, croup, and gastroenteritis Referral rates are shown annually for each condition and hospital volume category (thin lines). Curves of best fit (thick lines) were determined using logistic regression. Volume was categorized using quartile of pediatric visits to the ED each year.

Figure 2.

Multivariable modelling of referral rates for asthma, croup, and gastroenteritis Referral rate odds ratios are shown for each condition and each interaction model: unadjusted model, adjusted for age, adjusted for presence of complex chronic condition, and full multivariable model adjusted for age, sex, presence of CCC, weekend vs. weekday presentation, Medicaid vs. non-Medicaid insurance, location of ED, and area income.