Patient Insurance Status Is Associated With Care Received After Transfer Among Pediatric Patients in the Emergency Department

Acad Pediatr. 2021 Jul;21(5):877-884. doi: 10.1016/j.acap.2020.11.010. Epub 2020 Nov 20.


Objective: To determine whether frequency of interfacility transfer varied by insurance status among pediatric emergency department (ED) patients. Secondarily, we tested for an association between insurance status and odds of transfer with discharge from the second ED without observation or admission.

Methods: We used the 2016 New York State ED and Inpatient Databases to identify all patients <18 years. ED and hospital characteristics were from American Hospital Association and National ED Inventory-USA. Among all ED patients, we calculated the proportion transferred stratified by insurance status (private, public, none). Among ED-to-ED transfers, we identified transfers without subsequent observation or admission, and used hierarchical logistic regression modeling (adjusting for patient and transferring ED/hospital characteristics) to determine whether insurance status was associated with odds of discharge from the second ED without observation or admission.

Results: Of 1,303,575 pediatric ED visits, 6086 (0.5%) were transferred. Transfers were less frequent among patients with public or no insurance. Of 3801 ED-to-ED transfers, 1451 (38%) were without subsequent observation or admission. In bivariate and multivariable analysis, transferred patients with public and with no insurance were less likely to be discharged without observation or admission relative to privately insured patients.

Conclusion: Among ED-to-ED transfers, pediatric patients with public or without insurance were more often kept for observation or admission at the second hospital after transfer. Differences in disease acuity or in providers' perception of follow-up availability may play a role in explaining these patterns. This disparity merits further investigation.

Keywords: disparities; health insurance; transfer.

Publication types

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

MeSH terms

  • Child
  • Emergency Service, Hospital
  • Humans
  • Insurance Coverage
  • Insurance, Health
  • Medically Uninsured*
  • New York
  • Patient Transfer*
  • Retrospective Studies
  • United States