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. 2022 Feb 9;17(2):e0262490. doi: 10.1371/journal.pone.0262490

Disparities by race and insurance-status in declines in pediatric ED utilization during the COVID19 pandemic

Bisakha Pia Sen 1,*,#, Anne Brisendine 1,#, Nianlan Yang 2,#, Pallavi Ghosh 3,#
Editor: Jingjing Qian4
PMCID: PMC8827414  PMID: 35139099

Abstract

Pediatric Emergency Department (ED) utilization in the U.S. saw large declines during the COVID19 pandemic. What is relatively unexplored is whether the extent of declines differed by race and insurance status. An observational study was conducted using electronic medical record (EMR) data from the largest pediatric ED in Alabama for 2020 and 2019. The four subgroups of interest were African-American (AA), Non-Hispanic White (NHW), privately insured (PRIVATE), and publicly insured or self-insured (PUBLIC-SELF). Percentage changes in the 7-day moving average between dates in 2020 and 2019 were computed for total and high-severity ED visits by subgroup. Trends in percentage changes were plotted. T-tests were used to compare mean changes between subgroups. Large percentage declines in total ED visits and somewhat smaller percentage declines in high-severity visits were observed from March 2020. Declines were consistently larger for AA than NHW and for PUBLIC-SELF than PRIVATE. T-test results indicated mean date-specific percentage declines were significantly larger for AA than NHW for total visits (-38.92% [95% CI: -41.1, -36.8] versus -29.11% [95% CI: -30.8, -27.4]; p<0.001) and high-severity visits (-24.31% [95% CI: -26.2, -22.4] versus -19.49% [95% CI:-21.2, -17.8]; p<0.001), and larger for PUBLIC-SELF than PRIVATE for total visits (-36.32% [95% CI:-38.4, -34.3] versus 27.63% [95% CI:-29.2, -26.0]; p<0.001) and high-severity visits (-21.72% [95% CI: -23.5, -19.9] versus -20.01% [95% CI: -21.7, -18.3]; p = 0.04). In conclusion, significant differences by race and insurance status were observed in the decline in ED visits during the COVID19 pandemic, including high-severity visits. Minority-race and publicly insured or self-insured children often depend on the ED for health needs, lacking a usual source of care. Thus, these findings have worrisome implications regarding unmet healthcare needs and future exacerbations in health disparities.

Introduction

It is well documented that pediatric emergency department (ED) utilization in the United States declined sharply during the first several months of the COVID19 pandemic [1–5]. What is relatively unexplored is whether the magnitude of these declines differed by indicators of socioeconomic disadvantage, like minoritized race or being low-income. Racial minorities and low-income communities bore the brunt of adverse health and economic consequences from the COVID19 pandemic [6–8]; hence, their healthcare utilization may have been especially disrupted. Further, the decline in pediatric ED visits has been studied using single ED and multi-state ED data, but the single ED studies have largely focused on Northeastern states [2, 9, 10], and relatively little information exists about what happened to pediatric ED visits in Deep South states which are characterized by large African-American populations, high poverty, and poor performance on health indicators [11–13] as well as higher rates of ED use [14, 15] compared to the rest of the nation pre-pandemic. Hence, information on pediatric ED utilization and disparities therein during the COVID19 pandemic in this region is critical from a public health perspective. Further, the low COVID19 vaccination rates in the Deep South states–for example, Alabama and Mississippi at the end of September 2021 had fully vaccinated 52.0% and 53.2% of their populations respectively compared to Pennsylvania with 68.5% or New York with 75.3% fully vaccinated [16, 17]–implies that these states may remain vulnerable to the disruptions caused by COVID19 for a longer period of time than states in other parts of the country. Therefore, this study fills an important gap in the literature by investigating changes in pediatric ED visits and disparities therein in a Deep South state during the COVID19 pandemic.

Materials and methods

An observational study was conducted using data from the Children’s of Alabama ED (CoA-ED)–the largest pediatric ED in the state, located in the city of Birmingham (Jefferson County). CoA serves as a teaching hospital for the University of Alabama at Birmingham (UAB) [18]. CoA-ED is Alabama’s main tertiary care center for pediatric patients, the state’s only designated Level 1 pediatric trauma center. It saw approximately 72,000 pediatric patients per year between 2015 and 2019. In order to compare pre- and peri-COVID19 pandemic ED visit data for a full 12-month period, we selected January 1—December 31, 2019 and 2020 for the study period.

Using electronic medical record (EMR) data for pediatric patients aged 0–18 years presenting to the CoA-ED during January 1—December 31, 2019 and 2020, information on date of visit, race-ethnicity, insurance status, acuity, and disposition were extracted. ‘High-severity’ visits were defined as visits meeting any of the following: (i) in the 2 highest levels of acuity (on the 5-point scale Emergency Severity Index (ESI) based on acuity and resource-needs [19]); (ii) categorized as ‘trauma’ visits; and (iii) visits that resulted in inpatient admission. The four subgroups of interest were African-American (AA), Non-Hispanic White (NHW), privately insured (PRIVATE), and publicly insured or self-insured (PUBLIC-SELF). Due to small sample sizes, no subgroups were created for Hispanic, ‘other race’, or unknown and out-of-state insurance status, and they were omitted from the analyses.

To examine how the volume of total and high-severity ED visits changed over 2020 compared to 2019 for each of the 4 subgroups of interest, the following approach was used. First, daily counts of total and high-severity visits were computed for all dates in 2019 and 2020. Next, 7-day moving averages (MA7) were constructed for each date in order to smooth the variations in ED visit volume across weekdays and weekends that have been recorded in existing literature [20–23] and better compare changes in volume of visits for each date in 2020 compared to the same date in 2019, where dates fall on different days of the week between the two years. Next, “date-specific percentage changes”–i.e., percentage changes in MA7 for each date in 2020 compared to its corresponding date in 2019 were computed, omitting February 29, 2020. Date-specific percentage changes by subgroups were plotted for total visits and high-severity visits over January 7—December 31, 2020, since using MA7 necessitated exclusion of the first 6 days of January. Two-sided t-tests (significance at P<0.05) were used to compare differences in mean date-specific percentage changes between AA and NHW and between PUBLIC-SELF and PRIVATE for the full range of dates as well as for pre- and post-March 13, 2020 (the date when the U.S. declared a national emergency in response to COVID19 and the first case was detected in Alabama). As part of sensitivity analyses, we also compared PRIVATE with just publicly insured children (Medicaid and CHIP) while omitting self-pay.

Furthermore, because AA pediatric patients are more likely to be publicly insured or self-insured than privately insured compared to NHW patients, thus making it difficult to discern whether insurance-status played a role in change in ED visits over and beyond the role played by race, we also inspected whether there were differences in how visits changed for PUBLIC-SELF versus PRIVATE patients within the racial categories of AA and NHW. To do this, we repeated the previous steps and computed percentage changes in MA7 in total visits for patients who were African-American and privately insured (AA_PRIVATE), African-American and public or self-insured (AA_PUBLIC-SELF), Non-Hispanic White patients who were privately insured (NHW_PRIVATE) and Non-Hispanic White patients who were publicly insured or self-insured patients (NHW_PUBLIC-SELF). As a final step, we conducted two-sided t-tests to compare differences in mean date-specific percentage changes for AA_PRIVATE versus AA_PUBLIC-SELF, and for NHW_PRIVATE versus NHW_PUBLIC-SELF.

Stata (v16) was used for all analyses; R(v3.6.2) was used for graphs. The study protocol was approved by the UAB Institutional Review Board for Human Use.

Results

There was a combined total of 118,370 pediatric CoA-ED visits over 2019 and 2020 (Table 1), of which 28,504 met the definition of high-severity. Of these pooled total visits (high-severity visits), 48.9% (60.67%) were NHW; 49.5% (37.8%) were AA; 0.44% (0.34%) were Hispanic; and 1.2% (1.2%) were other race, biracial, or unknown. The last two groups were excluded from the analyses. Furthermore, 27.4% (33.2%) of total visits (high-severity visits) were PRIVATE and 72.2% (66.8%) were PUBLIC-SELF, which included 68.7% (64.7%) Medicaid or Children’s Health Insurance Program (CHIP), 3.5% (1.8%) self-insured, 0.3% (0.3%) out-of-state, and 0.04% (0.02%) unknown insurance status. Again, these last two groups were excluded from the analyses. In further breakdowns not shown in the table, it was seen that, in the final pooled sample, of the children who were NHW, 41.2% were PRIVATE and 58.8% were PUBLIC-SELF (56.1% publicly insured, 2.7% were self-insured), whereas of the children who were AA, 12.7% were PRIVATE and 87.3% were PUBLIC-SELF (82.7% were publicly insured and 4.6% were self-insured).

Table 1. Distribution of patient socioeconomic characteristics for pooled pediatric ED visits for Jan-Dec 2019 and 2020, Children’s of Alabama Emergency Department.

Total Visits High-Severity Visits
N = 118,370 N = 28,504
Race and Ethnicity N Percent N Percent
Non-Hispanic White 57907 48.92% 17282 60.63%
African-American 58581 49.49% 10775 37.80%
Hispanic a 521 0.44% 97 0.34%
Other Race/Biracial/Unknown a 1420 1.20% 351 1.23%
Insurance Status
Public (Medicaid or CHIP) 81320 68.70% 18445 64.71%
Self-Pay 4143 3.50% 505 1.77%
Private 32493 27.45% 9475 33.24%
Out of State a 367 0.31% 86 0.30%
Unknown a 47 0.04% 6 0.02%
Gender
Male 62073 52.44% 15130 53.08%
Female 56297 47.56% 13374 46.92%
Age-range
0–3 years 49112 41.49% 10048 35.25%
3<-6 years 17590 14.86% 3190 11.19%
6<-12 years 27770 23.46% 6944 24.36%
12<-18 years 23899 20.19% 8323 29.20%
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a The data are based on EMRs from Children’s of Alabama Emergency Department, the largest ED in the state. Due to small sample sizes, these sub-groups were excluded from the final analyses.

Date-specific percentage changes in 2020 compared to 2019 for total and high-severity ED visits are presented in Fig 1, with ‘0’ indicating no percentage change from one year to the next on the same date. Date-specific percentage changes for total visits for all groups became negative after March 13, 2020. The sharpest declines occurred in April and May of 2020, with greater than 70% declines for AA and PUBLIC-SELF and almost 60% declines for NHW and PRIVATE. A partial rebound happened from June to September 2020, especially for NHW and PRIVATE, which were just 10–20% lower than 2019 numbers, though visits for AA and PUBLIC-SELF were 40–50% lower. Percentage declines became steeper again after September 2020 and were particularly steep in November and December 2020. Percentage declines were consistently larger for AA compared to NHW, and for PUBLIC-SELF compared to PRIVATE.

Fig 1. Date−specific percentage changes of 7−day moving average on ED visits in total and high-severity ED visits in 2020 compared to 2019.

Fig 1

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It can also be seen from Fig 1 that date-specific percentage changes for high-severity visits also became negative after March 13, 2020, though the magnitudes of decline were smaller than total visits. There were brief and transient rebounds in the summer and fall of 2020, when the volume of visits matched or exceeded those of 2019, but they mostly showed a decline. While differences in declines between groups were less discernible for high-severity visits compared to total visits, they appeared to be larger for AA than NHW and for PUBLIC-SELF than PRIVATE.

T-test results (Table 2) indicated mean date-specific percentage declines in 2020 compared to 2019 were significantly larger for AA than NHW for total visits (-38.92% [95% CI: -41.1, -36.8] versus -29.11% [95% CI: -30.8, -27.4], p<0.001) as well as for high-severity visits (-24.31% [95% CI: -26.2, -22.4] versus -19.49% [95% CI:-21.2, -17.8], p<0.001). T-test results also indicate that mean date-specific percentage declines were larger for PUBLIC-SELF than PRIVATE for total visits (-36.32% [95% CI:-38.4, -34.3] versus 27.63% [95% CI:-29.2, -26.0], p<0.001) and for high-severity visits (-21.72% [95% CI: -23.5, -19.9] versus -20.01% [95% CI: -21.7, -18.3], p = 0.04). The differences in declines were more significant after March 13, 2020 (-46.37% for AA, -34.88% for NHW, p<0.001 for total visits; -28.91% for AA, -23.69% for NHW, p<0.001 for high-severity visits; -43.46% for PUBLIC-SELF, -32.87% for PRIVATE, p<0.001 for total visits, -26.61% for PUBLIC-SELF, -23.54% PRIVATE, p = 0.006 for high-severity visits). In contrast, mean date-specific percentage changes prior to March 13, 2020 were small, and differences between AA and NHW, and PUBLIC-SELF and PRIVATE largely insignificant. Sensitivity analyses comparing PRIVATE with just publicly insured children yielded virtually identical results.

Table 2. Differences in the mean date-specific percentage changes in 2020 compared to 2019 for total and high-severity ED visit counts by race and insurance status.

Mean Percentage Change in Total ED Visits Between 2019 and 2020 [95% C.I.]
African-American Children Non-Hispanic White Children P-value from T-test Publicly Insured or Self-Insured Children Privately Insured Children P-value from T-test
Jan 1-Dec 31, 2020 compared to 2019 -38.92 [-41.1, -36.8] -29.11 [-30.8, -27.4] P<0.001 -36.32 [-38.4, -34.3] -27.63 [29.2, -26.0] P<0.001
Jan 1-Mar 13, 2020 compared to 2019 -5.24 [-8.8, -1.7] -3.01 [-4.3, -1.7] P = 0.182 -3.98 [-7.0,-1.0] -3.90 [-5.1,-2.7] P = 0.904
Mar 13-Dec 31, 2020 compared to 2019 -46.37 [-47.8, -44.9] -34.88 [-36.2, -33.6] P<0.001 -43.48 [-44.9,-42.0] -32.87 [-34.2,-31.6] P<0.001
Mean Percentage Change in High-Severity ED Visits Between 2019 and 2020
African-American Children Non-Hispanic White Children P-value from T-test Publicly Insured or Self-Insured Children Privately Insured Children P-value from T-test
Jan 1-Dec 31, 2020 compared to 2019 -24.31 [-26.2, -22.4] -19.49 [-21.2, -17.8] P<0.001 -21.72 [-23.5,-19.9] -20.01 [-21.7,-18.3] P = 0.04
Jan 1- Mar 13, 2020 compared to 2019 -3.51 [-7.4, 0.4] -0.52 [-2.1, 1.1] P = 0.186 0.18 [-2.3,-2.7] -4.01 [-6.1, -1.8] P = 0.016
Mar 13-Dec 31, 2020 compared to 2019 -28.91 [-30.7, -27.2] -23.69 [-25.4, -22.0] P<0.001 -26.56 [-28.3, -24.9] -23.54 [-25.3, 21.8] P = 0.001
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Notes: Date-specific percentage changes were computed by calculating differences in 7-day moving averages for 2020 from the 7-day moving averages of the corresponding dates in 2019. Hispanic, “other race”, out-of-state insurance, and unknown insurance were not analyzed due to small sample size.

T-test results comparing mean date-specific percentage changes in total visits for AA_PRIVATE versus AA_PUBLIC-SELF, and for NHW_PRIVATE versus NHW_PUBLIC-SELF are shown in Table 3. These results indicated that mean date-specific percentage declines in 2020 compared to 2019 were significantly larger for AA_PUBLIC-SELF than AA_PRIVATE (-40.07% [95% CI: -42.3, -37.9] compared to -34.15% [95% CI: -36.5, -31.8], p<0.001, and were also significantly larger for NHW_PUBLIC-SELF than NHW_PRIVATE (-31.95% [95% CI: -33.9, -29.9] compared to -25.95% [95% CI: -27.6, -24.3], p<0.001). As with previous results, the declines were larger and the differences in declines were more significant after March 13, 2020.

Table 3. Differences in the mean date-specific percentage changes in 2020 compared to 2019 for total ED visit counts between privately insured & publicly/self-insured children, by race.

Mean Percentage Change in Total ED Visits Between 2019 and 2020 [95% C.I.]
African-American Children Non-Hispanic White Children
Publicly Insured or Self-Insured Children Privately Insured Children P-value from T-test Publicly Insured or Self-Insured Children Privately Insured Children P-value from T-test
Jan 1-Dec 31, 2020 compared to 2019 -40.07 [-42.3, -37.9] -34.15 [-36.5, -31.8] P<0.001 -31.95 [-33.9, -29.9] -25.95 [-27.6, -24.3] P<0.001
Jan 1-Mar 13, 2020 compared to 2019 -6.82 [-10.6, -3.0] -1.82 [-6.7, 3.1] P = 0.03 -1.87 [-4.7, 1.0] -4.10 [-5.9, -2.3] P = 0.28
Mar 13-Dec 31, 2020 compared to 2019 -47.10 [-48.7, -45.5] -40.99 [-42.8, -39.2] P<0.001 -38.31 [-39.8, -36.8] -30.57 [-31.9, -29.2] P<0.001
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Notes: For each sub-group, date-specific percentage changes were computed by calculating differences in 7-day moving averages for 2020 from the 7-day moving averages of the corresponding dates in 2019.

Discussion

A growing literature has documented declines in pediatric ED visits in the U.S. during the first several months of the COVID19 pandemic [1–5]. However, the question of whether there were disparities in these declines by race and insurance status is relatively unexplored, beyond two single-ED studies that considered racial differences in changes in ED visits for mental health [9, 10]. The primary aim of this study was to address this gap and investigate differences in declines for children in the AA, NHW, PUBLIC-SELF, and PRIVATE groups. A secondary aim was to compare declines for children in the PUBLIC-SELF and PRIVATE subgroups within the categories of AA and NHW. Results showed that, during March to December 2020, relative declines in total ED visits as well as high-severity ED visits were larger for children in the AA and PUBLIC-SELF groups than for children in the NHW and PRIVATE groups. Declines were also significantly higher for the PUBLIC-SELF subgroup compared to PRIVATE subgroups for both the categories AA and children.

This paper’s findings of steep declines in pediatric ED visits starting in March 2020, followed by a partial rebound from June to September 2020, and then a subsequent decline after September 2020, are consistent with existing literature (S1 Fig, Adjemian, 2021, https://stacks.cdc.gov/view/cdc/104808) [4]. However, separating the analyses by groups reveals that the rebound was mostly for children in the PRIVATE and NHW groups. This is important from a public health perspective. AA and economically-disadvantaged communities, who are likely to be publicly insured or self-insured, disproportionately use the ED for pediatric healthcare needs [24], as they often lack access to a usual source of care. Given that the larger declines were seen for high-severity visits as well, it is possible that urgent healthcare needs went unmet for disadvantaged children.

This study also contributed by focusing on a Deep South state. Most single-ED studies on this topic area have focused on Northeastern states [2, 9, 10], and one multi-state study that looked at race-ethnicity as a variable of interest found only a small decline in the share of AA patients–from 22.3% in pre-COVID19 years to 21.4% in 2020 [1]. This is markedly different from this study’s finding, and it underscores the possibility that multi-state studies will mask region-specific variations in decline in healthcare utilization during the pandemic. Hence, greater focus on trends in states with large shares of disadvantaged pediatric populations is warranted.

The data used in this study does not permit deciphering whether the decline in ED visits portends unmet healthcare needs or whether it happened because of reduced incidence of illness and injury due to school closures and stay at home ordinances. However, along with the greater decline in ED visits found in this study for children in the AA and PUBLIC-SELF groups, there is evidence of relatively greater declines in pediatric vaccination in Michigan among publicly-insured children [25], worsening racial disparities in pediatric obesity in Pennsylvania [26], and–despite reports of worsening pediatric mental health during the pandemic [27]–disproportionate declines in pediatric ED visits for mental health for AA children than NHW children in Connecticut [9] and Pennsylvania [10]. Finally, preliminary (unpublished) findings from a pilot project by this team suggests that AA and low-income children were less likely to access telehealth than their NHW and higher income counterparts; therefore, it is unlikely that care provided via telehealth compensated for the declines in ED visits for these disadvantaged groups. Taken in conjunction, these findings strongly indicate that essential healthcare was foregone by minority and low-income communities, and disparities in pediatric health conditions likely worsened during the COVID19 pandemic.

This study has certain limitations. First, the information was derived from EMR data; there was no information on reasons why patients did not come to the ED, whether care was being accessed in alternate settings such as via urgent care or office visits, or whether there were subsequent adverse health consequences of foregone or delayed care. Second, though the Hispanic community has been hard-hit by the COVID19 pandemic, the sample of Hispanic patients using the CoA-ED was too small to permit meaningful examination of changes in their ED use. Third, the EMR data received from CoA-ED did not include ICD-10 codes for diagnosis or claims, so this study could not document or tabulate conditions with which patients were presenting; thus, it cannot be deciphered how many pediatric patients were presenting with COVID19 infections, particularly in the latter part of 2020. Finally, this is a single-ED study, which limits generalizability but, since Alabama shares several socio-demographic and economic characteristics with other Deep South states [11–13, 28], findings from the largest pediatric ED in Alabama are likely to be pertinent for those states as well.

Conclusion

This study found that, in a part of the country that already performs poorly in health and socio-economic metrics, declines in pediatric ED visits were disproportionately and persistently larger for AA children compared NHW children, and for economically disadvantaged children–as indicated by publicly insured or self-insured status–compared to privately-insured children. These differences in declines were apparent for total visits and for high-severity visits. Given the relatively slow uptake of COVID19 vaccines in this region of the country, and the continued risk that new variants of the virus can emerge, it is likely that disruptions to healthcare utilization caused by the pandemic may persist in the near future. Hence, surveillance by healthcare systems and providers is urgently called for to detect and minimize future health consequences from foregone pediatric ED care, particularly among disadvantaged pediatric populations.

Data Availability

The data (minimal anonymized data set and any additional data required to replicate the reported study finding in their entirety) has been made publically available (without any PHI): Your openICPSR Project openicpsr-152201: Published Access the deposit workspace at: https://www.openicpsr.org/openicpsr/workspace?goToPath=/openicpsr/152201&goToLevel=project View the published project: https://www.openicpsr.org/openicpsr/project/152201/version/V1/view.

Funding Statement

This research was partially supported by an internal grant from the Office of the Dean, Lister Hill Center for Health Policy, and Sparkman Center for Global Health at the School of Public Health, UAB. No other external funding was received for this grant. The funders provided support in the form of salaries for the statistician for the project, Dr Nianlan Yang, and for graduate research assistants, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. While corresponding author Dr Bisakha Sen, and co-author Dr. Anne Brisendine are faculty in the Department of Health Care Organization & Policy, School of Public Health, UAB, they have no direct affiliation with the Office of the Dean, Lister Hill Center for Health Policy, or Sparkman Center for Global Health, and this does not impact the authors’ adherence to PLOS ONE policies on sharing data and materials.

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Decision Letter 0

Jingjing Qian

Transfer Alert

This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present.

24 Sep 2021

PONE-D-21-26799Disparities by Race and Insurance-Status in Declines in Pediatric ED Utilization During the COVID-19 Pandemic.PLOS ONE

Dear Dr. Sen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 08 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Jingjing Qian

Academic Editor

PLOS ONE

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 [The authors were partially supported through an internal grant by the School of Public Health, University of Alabama at Birmingham. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.]

  

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[The authors were partially supported through an internal grant by the School of Public Health, University of Alabama at Birmingham. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.]. 

We note that one or more of the authors is affiliated with the funding organization, indicating the funder may have had some role in the design, data collection, analysis or preparation of your manuscript for publication; in other words, the funder played an indirect role through the participation of the co-authors. 

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This study evaluates the trends in pediatric emergency department visits in 2019 and 2020 (during the COVID-19 pandemic). The authors evaluate these trends in subgroups based on race, ethnicity, and insurance status. In addition, the study addresses an important topic given the well-known racial disparities further revealed by COVID, especially in the southern United States. Some issues with the methods and results reporting need to be clarified/addressed. Please see below for more specific comments by section:

Introduction:

• More references are needed to support a few of the statements made in the introduction.

o The 4th sentence ending in “…higher rates of ED use compared to the rest of the nation pre-pandemic” needs more support.

o Additionally, the penultimate sentence in that section needs more detail regarding vaccination rates and disparities specific to the region, perhaps as it compares to the Northeastern states mentioned earlier.

Methods:

• Study site: Please provide some more detail about the study site including annual patient volume, tertiary/teaching, etc. to help the audience draw conclusions regarding generalizability of the results.

• Study dates: I suspect the study periods were chosen to compare pre- and peri-pandemic data in a full 12 month period, however, please clarify rationale for selecting these dates.

• While the variables provided are laid out clearly, some more detail is necessary to develop a better picture of the dataset. If available, some more demographic data would be helpful to compare the 2019 and 2020 groups, specifically age.

• Please clarify further the 5-point acuity scale – is this ESI?

• Smoothing: Please provide some references for rationale.

Results:

• Throughout this section, please specify the years for each month mentioned for consistency and clarification.

• Consider combining the third and fourth paragraphs of this section to better incorporate the numbers (paragraph 4) alongside the text (paragraph 3).

• Table 1 – Clearly presented overall. Please provide the raw numbers alongside the percentages.

• Figure 1 – Please include the years on each graph. Per the title of the figure, the figures are comparing 2020 and 2019, but this should be clarified with labels.

• Table 2 – Very important table! Please clarify dates in the first column (All 12 months, up to March 13, after March 13) with years and specific time periods (e.g. January 1, 2020-December 31, 2020; January 1, 2020 – March 13, 2020; March 14, 2020-December 31, 2020). Additionally, please report 95% confidence intervals in this table. Worth highlighting this in the text (including abstract).

Discussion:

• The discussion here is interesting and keeps with the paper’s focus. The authors have done a good job addressing all the major points. However, parts of the discussion would benefit from some more detail and support from the literature.

• The following statements should be discussed in more detail and/or supported with findings from the literature:

o The first sentence in the discussion – “Growing literature has documented declines…” – please cite the literature here.

o Supplementary Figure 1 by Adjemian et al. was not included in the document.

o Please expand on inability to document specific health conditions. As the authors mention, this is an important limitation.

o The sentence – “…since Alabama shares several socio-demographic and economic characteristics with other Deep South states” – please support this statement as well.

Additionally, there are some minor grammatical and typographic errors (i.e. U.S. instead of United States on first use in the introduction) – please check for these throughout the document.

Reviewer #2: The authors set out to explore the differences in the utilization of the ED at a major pediatric emergency department in Alabama during the Covid-19 pandemic based on racial and socioeconomic factors. The authors found a significantly larger decline in ED utilization by the African-American and publicly insured or self-insured patients in comparison to non-Hispanic white and privately insured patients, respectively. These findings inform the reader of the further worsening of healthcare disparities in the pandemic environment and suggest an exacerbation of unmet healthcare needs of vulnerable populations.

1. Parts of the manuscript are somewhat difficult to read. I recommend reviewing the revised manuscript for grammar and syntax errors.

2. It appears that the authors chose to group publicly- and self-insured patients together. What was the breakdown of those groups? Are those populations truly comparable enough to be considered together?

3. The age range of the patients was not defined. Was there a difference among groups? This could be another variable relevant for analysis.

4. Was there an overlap in the two sets of groups (AA and NHW and between PUBLIC-SELF and

PRIVATE)? In other words, for instance, was there a difference in the AA + PUBLIC-SELF and AA + PRIVATE? Is possible that the difference is more related to the race or the insurance status?

5. Results Section, paragraph 2, last sentence: the statement is somewhat ambiguous, as it appears to imply that the groups were combined (AA and PUBLIC vs. NHW and PRIVATE)

6. Page 7, Discussion, sentence starting with: While this paper’s findings of steep declines… is unclear the way it is written.

7. The authors make a great point discussing the lower rates of utilization of telemedicine among African American and low income children. However, is there any data on urgent care use? Is it possible that the people were more likely to take their children to urgent care facilities due to shorter lines and more predictable wait times, especially for low-severity visits?

**********

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2022 Feb 9;17(2):e0262490. doi: 10.1371/journal.pone.0262490.r002

Author response to Decision Letter 0

27 Oct 2021

We have uploaded a separate file that includes details of how we responded to each comment by the editor and reviewers. We want to draw specific attention to the funding statement which was an issue that had been raised by the editor (this is also in our Response file, but deserves highlighting). Our new funding statement reads as follows:

"This research was partially supported by an internal grant from the Office of the Dean, Lister Hill Center for Health Policy, and Sparkman Center for Global Health at the School of Public Health, UAB. No other external funding was received for this grant. The funders provided support in the form of salaries for the statistician for the project, Dr Nianlan Yang, and for graduate research assistants, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. While corresponding author Dr Bisakha Sen, and co-author Dr. Anne Brisendine are faculty in the Department of Health Care Organization & Policy, School of Public Health, UAB, they have no direct affiliation with the Office of the Dean, Lister Hill Center for Health Policy, or Sparkman Center for Global Health, and this does not impact the authors’ adherence to PLOS ONE policies on sharing data and materials. Dr Pallavi Ghosh is attending physician at CoA-ED, from where the data for this research were obtained. CoA-ED had no role in the research beyond providing the data, and this also does not impact the authors’ adherence to PLOS ONE policies on sharing data and materials."

Attachment

Submitted filename: PLoS One Response to Reviewers.docx

Click here for additional data file. (45KB, docx)

Decision Letter 1

Jingjing Qian

15 Nov 2021

PONE-D-21-26799R1Disparities by Race and Insurance-Status in Declines in Pediatric ED Utilization During the COVID-19 Pandemic.PLOS ONE

Dear Dr. Sen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 30 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Jingjing Qian

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thanks the authors for addressing most of the reviewers' comments. In the next revision, please:

1) edit text to clarify the comparisons between AA and NHW, and between Public-self and Private throughout to avoid any confusions as suggested by Reviewer 2. For example, the last sentence in the 2nd paragraph of the Results section, "Percentage declines were consistently larger for AA and PUBLIC-SELF than NHW and PRIVATE." This is confusing and you did not revise as suggested by Reviewer 2. This is one example but please read the entire manuscript to improve clarify of writing.

2) the author's response to Reviewer 2's question regarding the overlap between AA+Public-self and AA+Private is not convincing. Please provide results for the direct comparison between these 2 subgroups in table and in text.

3) please giving the manuscript another read through for grammar and syntax prior to final submission as suggested by Reviewer 1.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed the initial concerns. I would recommend giving the manuscript another read through for grammar and syntax prior to final submission.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Feb 9;17(2):e0262490. doi: 10.1371/journal.pone.0262490.r004

Author response to Decision Letter 1

30 Nov 2021

We have uploaded a file that details how we responded to the remaining concerns from editor and reviewers. Please let us know if anything further is needed.

Attachment

Submitted filename: PLoS One Response to Reviewers ROUND2.docx

Click here for additional data file. (18.1KB, docx)

Decision Letter 2

Jingjing Qian

27 Dec 2021

Disparities by Race and Insurance-Status in Declines in Pediatric ED Utilization During the COVID-19 Pandemic.

PONE-D-21-26799R2

Dear Dr. Sen,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Jingjing Qian

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you!

Reviewers' comments:

Acceptance letter

Jingjing Qian

17 Jan 2022

PONE-D-21-26799R2

Disparities by race and insurance-status in declines in pediatric ED utilization during the COVID19 pandemic

Dear Dr. Sen:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Jingjing Qian

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

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    Attachment

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    Data Availability Statement

    The data (minimal anonymized data set and any additional data required to replicate the reported study finding in their entirety) has been made publically available (without any PHI): Your openICPSR Project openicpsr-152201: Published Access the deposit workspace at: https://www.openicpsr.org/openicpsr/workspace?goToPath=/openicpsr/152201&goToLevel=project View the published project: https://www.openicpsr.org/openicpsr/project/152201/version/V1/view.

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