Trends in Regionalization of Emergency Care for Common Pediatric Conditions

Pediatrics. 2020 Apr;145(4):e20192989. doi: 10.1542/peds.2019-2989. Epub 2020 Mar 13.


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.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Asthma / therapy*
  • Child
  • Child, Preschool
  • Confidence Intervals
  • Cross-Sectional Studies
  • Croup / therapy*
  • Databases, Factual
  • Emergency Service, Hospital / statistics & numerical data
  • Emergency Service, Hospital / trends
  • Emergency Treatment / statistics & numerical data
  • Emergency Treatment / trends*
  • Gastroenteritis / therapy*
  • Humans
  • Logistic Models
  • Patient Transfer / statistics & numerical data
  • Patient Transfer / trends
  • Referral and Consultation / statistics & numerical data
  • Referral and Consultation / trends*
  • United States
  • United States Agency for Healthcare Research and Quality / statistics & numerical data