To the editor
Concerns regarding cost, continuity of care, and crowding continue to bring ED utilization under increasing nationwide scrutiny.1 Though many hope that increasing insurance coverage through the Affordable Care Act will lead to decreases in ED visits, recent evidence in adults suggests that increasing access to specifically Medicaid insurance may actually be associated with increased ED use.2,3 This ongoing discussion regarding the association between insurance coverage and ED use, however, has focused primarily on adults. Most prior research on trends in ED utilization in children predates the recent economic downturn and associated changes in insurance coverage,4,5 or analyzes reported use per person rather than actual visit rates.6
Methods
We conducted a retrospective analysis of all ED visits by children aged 18 and under to non-federal general, acute care hospitals across California between 2005 and 2010, using non-public versions of the California Office of Statewide Health Planning and Development's Emergency Discharge and Patient Discharge Datasets. We excluded records with missing sex (0.05%), scheduled admissions (17.4%), admissions not from the hospital's ED (0.5%), and visits covered by Medicare (0.5%).
We grouped ED visits into four categories: Medicaid, private insurance, uninsured, and other. To construct rates of ED visits per 1000 children for insurance groups, we used data from the State Health Access Data Assistance Center (SHADAC), derived from the Census Bureau's Current Population Survey. Using Stata version 11, we compared the distribution of visits by payer across years using a chi-squared test, and tested for the significance of trends in visit rates by payer using an ordinary least squares regression allowing for payer-specific linear trends in rates, Statistical significance was assessed using two-sided tests with a critical value of 0.05. This study was approved by the UCSF Committee on Human Research.
Results
The number of visits to California EDs by children rose from 2.5 million in 2005 to 2.8 million in 2010, an 11% increase (Table). Children covered by Medicaid accounted for 44% of all ED visits. The distribution of visits across payer groups changed significantly between 2005 and 2010, with Medicaid accounting for a larger share over time (p<0.01).
Table 1. Characteristics of California ED visits by children (≤ 18 years old), 2005-2010a.
| 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | Total | % increase in visits 2005-2010 | |
|---|---|---|---|---|---|---|---|---|
| Visits by insurance statusb, No. (%) | ||||||||
| Private | 1074 (43) | 1034 (42) | 1059 (41) | 1077 (41) | 1190 (39) | 1071 (38) | 6505 (41) | -0.3 |
|
| ||||||||
| Medicaid | 1020 (40) | 1014 (41) | 1089 (42) | 1160 (44) | 1429 (47) | 1359 (48) | 7071 (44) | 33.2 |
|
| ||||||||
| Uninsured | 276 (11) | 288 (12) | 298 (12) | 277 (11) | 296 (10) | 263 (9) | 1698 (11) | -4.7 |
|
| ||||||||
| Other | 153 (6) | 147 (6) | 138 (5) | 111 (4) | 122 (4) | 110 (4) | 780 (5) | -28.4 |
|
| ||||||||
| Visits by ageb, No. (%) | ||||||||
| 0-5 years | 1264 (50) | 1241 (50) | 1315 (51) | 1335 (51) | 1524 (50) | 1423 (51) | 8103 (50) | 12.6 |
|
| ||||||||
| 6-18 years | 1259 (50) | 1241 (50) | 1268 (49) | 1291 (49) | 1513 (50) | 1379 (49) | 7952 (50) | 9.6 |
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| Visits by sexb, No. (%) | ||||||||
| Male | 1354 (54) | 1333 (54) | 1389 (54) | 1404 (53) | 1615 (53) | 1489 (53) | 8585 (53) | 10.0 |
|
| ||||||||
| Female | 1169 (46) | 1150 (46) | 1195 (46) | 1222 (47) | 1422 (47) | 1313 (47) | 7470 (47) | 12.3 |
|
| ||||||||
| Total Visits, No. (%) | 2523 (100) | 2483(100) | 2583 (100) | 2626 (100) | 3037 (100) | 2802 (100) | 16055 (100) | 11.1 |
|
| ||||||||
| Increase from previous year, No. (%) | NA | -40 (-1.6) | 101 (4.1) | 43 (1.7) | 411 (15.7) | -235 (-7.7) | NA | NA |
The distribution of ED visits by insurance status in each year 2006-2010 is different from the distribution of visits in 2005 (p<0.01 in all cases; pairwise tests). Chi-square tests also indicate that the distributions are jointly significantly different across years (p<0.01).
Visit rates reflect estimated ED visits in the 1000s.
After adjusting for population (given a 3% decrease in the pediatric population during our study period) to obtain ED visit rates, the rate of ED use rose significantly across all insurance groups (p<0.01 in all cases), with a notable increase during 2009 (Figure). Uninsured California children exhibited the fastest rise in ED visit rates, from 202 to 248 visits per 1000 (22.7%), followed by privately insured children (176 to 202 visits per 1000; 15.0%). The rate of ED use among children covered by Medicaid exhibited the slowest growth, rising from 341 to 366 visits per 1000 (7.4%), but remained the highest in absolute terms.
Figure 1. ED visit rates among children (≤ 18 years old) by payer, 2005-2010.
An analysis of linear trend was conducted to compare changes in rates over time across payers. Differences in the trends in rates for payers shown are statistically significant (p<0.01).
Discussion
In contrast to older literature documenting decreases or no change in children's rates of ED use in the 1990's and early 2000's,4,5 we find that rates of ED use by children have gone up across all payers. While among adults Medicaid patients have the fastest-growing rates of ED use,3 the largest increases in ED visit rates for children are not among Medicaid beneficiaries but rather among the privately insured and uninsured. Shifts in insurance (from private and no insurance to Medicaid) during the recession (December 2007-June 2009) likely influenced the trends during this time. These findings suggest that the drivers for ED use differ significantly between children and adults and that policies regarding insurance expansion may also have varying effects. The divergence from older trends in ED use among children may also reflect the increasingly central role of the ED in the U.S. healthcare system, especially during a period of severe economic recession, and could signal an overall deterioration in children's access to primary care across payer groups, or that even privately insured children with greater access to primary care physicians are being directed to the ED for care.
Our findings are limited by our administrative data, which are self-reported by hospitals to the State, and may not be generalizable outside of California. In addition, we evaluated unique visits rather than unique patients.
Acknowledgments
We are grateful to Nicole Gordon, BA (Department of Emergency Medicine, UCSF), and Suzanne Wilson, MPH (Center for Health Policy, Stanford University) for their technical assistance in the early stages of this project. Both were compensated as employees for their contributions by their respective Universities. Ms. Gordon is currently at medical student at University of Quinnipiac School of Medicine. Drs. Hsia and Baker had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. This study was primarily funded by a grant from the California HealthCare Foundation. Additional support was provided by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number KL2 TR000143 (R.Y.H.), and the Robert Wood Johnson Foundation Physician Faculty Scholars Program (R.Y.H.). The sponsors had no role in the design and conduct of the study; collection, analysis, and interpretation of data; or preparation, review, or approval of the manuscript. The authors have no conflicts of interest to report.
References
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