School of Public Health study is first to look at frequent emergency room visits in multiple states over multiple years

A new study by a team including two researchers with the Texas A&M University School of Public Health found that about 3 percent of pediatric patients who seek treatment at hospital emergency departments (EDs) account for more than 10 percent of all ED visits.

The finding was part of the first known study of the diverse factors behind two different uses of EDs by children and young adults—visits caused by health issues that are chronic and persistent, and those that are temporary and frequent—over multiple years and at multiple hospitals. The work is part of a continuing research effort led by the Population Informatics Lab on appropriate Emergency Department Utilization using the Healthcare Cost and Utilization Project (HCUP) as well as Texas ED data. This study builds on previous work by the Texas A&M Population Informatics Lab that was published in 2020.

The study was conducted by Benjamin Ukert, PhD, and Hye-Chung Kum, PhD, director of the Population Informatics Lab with the Department of Health Policy and Management, along with four other colleagues. The study was published in the journal Academic Pediatrics.

“Children account for about 20 percent of all ED visits in the United States,” Ukert said. “But these visits are not distributed uniformly across that age group. We wanted to follow children who were without a history of ED visits to find out if they became pediatric frequent ED users over a period of years.”

The researchers conducted a retrospective, secondary, longitudinal data analysis of ED data provided by HCUP, the nation’s most comprehensive hospital care database, for 2011-2017 for Florida, Massachusetts and New York. These states were among the few that consistently submitted ED data to HCUP for the years studied and that also used a patient identifier system that made a longitudinal study feasible.

“Many factors contribute to pediatric frequent ED visits, including lack of private health insurance, living in economically disadvantaged areas and having multiple and complex chronic physical and mental disorders,” Kum said.

Although interventions such as care coordination and increasing parents’ knowledge of care have been adopted to reduce repeat ED revisits, most prior research that led to these interventions focused on the short term: revisits within 72 hours or within 12 months after the initial visit. Given that the health issues of many pediatric frequent ED users are acute—severe and sudden—and not chronic, this focus can result in conflicting research findings. In addition, most of these studies rely on databases from specific hospitals or states, which cannot provide a longitudinal study over multiple years or across multiple ED settings.

The study assessed 1.3 million pediatric ED users across the three states and found that 2.9 percent of patients (37,558) were frequent ED users, accounting for 10.2 percent (181,138) of all ED visits in 2012. Only a small share of this group needed frequent and continuous use of EDs over the entire study period, however. On the other hand, persistent pediatric frequent ED users had disproportionately higher intensity of ED use in2012, as well as more chronic conditions and comorbidities. Patients in this group were more likely to have public or inconsistent health insurance coverage over time, to live in non-metropolitan or lower-income areas, and to have more ED visits for conditions that were preventable or could be treated by non-emergency care in 2012.

Only 15.4 percent and 2.2 percent of pediatric frequent ED users in 2012 remained periodic and persistentED users across the study period, findings that are consistent with those for adult patients. In addition, more than half of the ED visits by those with persistent and frequent ED use were for less urgent conditions. While these patients likely would be better served in outpatient situations, obstacles such as lack of transportation, difficulty finding physicians and setting appointments, and language barriers make outpatient care unlikely for about one-third of children in the United States.

Overall, the findings suggest that health care outcomes could be improved and the cost of ED visits lowered if hospital systems, clinicians and policymakers recognized the very different types and durations of health issues when designing and implementing health interventions.