Comparison of emergency care delivered to children and young adults with complex chronic conditions between pediatric and general emergency departments.

Objectives Increasing attention is being paid to medically complex children and young adults, such as those with complex chronic conditions, because they are high consumers of inpatient hospital days and resources. However, little is known about where these children and young adults with complex chronic conditions seek emergency care and if the type of emergency department (ED) influences the likelihood of admission. The authors sought to generate nationwide estimates for ED use by children and young adults with complex chronic conditions and to evaluate if being of the age for transition to adult care significantly affects the site of care and likelihood of hospital admission. Methods This was a cross-sectional study using discharge data from the 2008 Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality to evaluate visits to either pediatric or general EDs by pediatric-aged patients (17 years old or younger) and transition-aged patients (18 to 24 years old) with at least one complex chronic condition. The main outcome measures were hospital admission, ED charges for treat-and-release visits, and total charges for admitted patients. Results In 2008, 69% of visits by pediatric-aged and 92% of visits by transition-aged patients with multiple complex chronic conditions occurred in general EDs. Not surprisingly, pediatric age was the strongest predictor of seeking care in a pediatric ED (odds ratio [OR] = 15.86; 95% confidence interval [CI] = 12.3 to 20.5). Technology dependence (OR = 1.56; 95% CI =1.2 to 2.0) and presence of multiple complex chronic conditions (OR = 1.39; 95% CI = 1.2 to 1.6) were also associated with higher odds of seeking care in a pediatric ED. When controlling for patient and hospital characteristics, type of ED was not a significant predictor of admission (p = 0.87) or total charges (p = 0.26) in either age group. Conclusions Overall, this study shows that, despite their complexity, the vast majority of children and young adults with multiple complex chronic conditions are cared for in general EDs. When controlling for patient and hospital characteristics, the admission rate and total charges for hospitalized patients did not differ between pediatric and general EDs. This result highlights the need for increased attention to the care that these medically complex children and young adults receive outside of pediatric-specialty centers. These results also emphasize that any future performance metrics developed to evaluate the quality of emergency care for children and young adults with complex chronic conditions must be applicable to both pediatric and general ED settings. Resumen Objetivos Cada vez se presta mas atencion a los ninos y adultos jovenes medicamente complejos, como aquellos con enfermedades cronicas complejas (ECC), debido a que son grandes consumidores de dias de estancia y recursos hospitalarios. Sin embargo, se sabe poco sobre donde estos ninos y adultos jovenes con ECC buscan atencion urgente y si el tipo de servicio de urgencias (SU) influye en la probabilidad de ingreso. Los autores trataron de generar estimaciones nacionales del uso del SU por ninos y adultos jovenes con ECC y evaluar si estar en la edad de transicion a los cuidados de adultos afecta significativamente el lugar de atencion y la probabilidad de ingreso hospitalario. Metodologia Estudio transversal usando la Nationwide Emergency Department Sample (NEDS) de 2008 para evaluar las visitas tanto a SU pediatricos como generales por pacientes de edad pediatrica (≤ 17 anos) y en edad de transicion (de 18 a 24 anos) con al menos una ECC. Las principales medidas de resultado fueron la presentacion a un SU pediatrico, el ingreso hospitalario, los costes para visitas con tratamiento y alta directa del SU y los gastos totales de pacientes ingresados. Resultados En 2008, un 69% de las visitas de pacientes en edad pediatrica con multiples ECC y un 92% en el caso de los pacientes en edad de transicion ocurrieron en SU generales. Como era de esperar, la edad pediatrica fue el predictor mas fuerte de busqueda de atencion en un SU pediatrico (odds ratio [OR] = 15,86; intervalo de confianza [IC] 95% = 12,3–20,5). La dependencia de la tecnologia (OR = 1,56, IC 95% = 1,2 a 2,0) y la presencia de multiples ECC (OR = 1,39, IC 95% = 1.2 a 1.6) tambien se asociaron con mayor probabilidad de buscar atencion en un SU pediatrico. Tras ajustar por las caracteristicas del paciente y del hospital, el tipo de SU no fue un factor predictivo significativo de ingreso (p = 0,87) o de costes totales en cada grupo de edad (p = 0,26). Conclusiones En general, este estudio muestra que, a pesar de su complejidad, la gran mayoria de los ninos y adultos jovenes con multiples ECC son atendidos en SU generales. Tras controlar por las caracteristicas del paciente y del hospital, el porcentaje de ingreso y los gastos totales para los pacientes ingresados no difirieron entre SU generales y pediatricos. Este resultado destaca la necesidad de una mayor atencion a la asistencia medica que estos ninos y adultos jovenes medicamente complejos reciben fuera de centros especializados en pediatria. Estos resultados tambien enfatizan que cualquier medida futura de rendimiento desarrollada para evaluar la calidad de la atencion urgente de ninos y adultos jovenes con ECC debe ser aplicable tanto a SU generales como pediatricos.