Elsevier

Academic Pediatrics

Volume 9, Issue 1, January–February 2009, Pages 33-39
Academic Pediatrics

Emergency Department Use
Primary Care Quality and Subsequent Emergency Department Utilization for Children in Wisconsin Medicaid

https://doi.org/10.1016/j.acap.2008.11.004Get rights and content

Objective

Children enrolled in Medicaid have disproportionately high emergency department (ED) visit rates. Despite the growing importance of patient reported quality-of-care assessments, little is known about the association between parent-reported quality of primary care and ED utilization for these high-risk children. Our goal was to determine the association between parent-reported primary care quality and subsequent ED utilization for children in Medicaid.

Methods

We studied a retrospective cohort of children enrolled in Wisconsin Medicaid. Parents of children sampled during fall 2002 and fall 2004 completed Consumer Assessment of Healthcare Providers and Systems surveys assessing their child's primary care quality in 3 domains: family centeredness, timeliness, and realized access. Primary outcomes were the rates of subsequent nonurgent and urgent ED visits, extracted from claims data for the year after survey completion. Negative binomial regression was used to determine the association between the domains of care and ED utilization.

Results

A total of 5468 children were included. High-quality family centeredness was associated with a 27% (95% confidence interval [95% CI] 11%–40%) lower nonurgent ED visit rate, but no lowering of the urgent visit rate. High-quality timeliness was associated with 18% (95% CI, 3%–31%) lower nonurgent and 18% (95% CI, 1%–33%) lower urgent visit rates. High-quality realized access was associated with a 27% (95% CI, 8%–43%) lower nonurgent visit rate and a 33% (95% CI, 14%–48%) lower urgent visit rate.

Conclusions

Parent-reported high-quality timeliness, family centeredness, and realized access for a publicly insured child are associated with lower nonurgent ED, with high-quality timeliness and realized access associated with lower urgent ED utilization.

Section snippets

Study Population and Source of Data

This is a retrospective cohort analysis linking the results of cross-sectional CAHPS surveys evaluating quality of primary care to subsequent ED utilization as determined by analysis of administrative Medicaid data.

The study population combines 2 cohorts of children, one cohort from 2002 and the other from 2004. In the fall of 2002 and again in the fall of 2004, the Wisconsin Department of Health and Family Services sent CAHPS surveys to randomly selected enrollees in the Wisconsin Managed Care

Results

A total of 5582 children had completed CAHPS surveys, of which 114 were excluded for incomplete subsequent enrollment. The final cohort of children was very similar in age and gender to the population of all children enrolled in the Managed Care Medicaid program as determined by comparison to enrollment data from the Department of Health and Family Services. Of the 5468 children in the final cohort, 1540 children (28.2%) made a total of 2792 ED visits during the follow-up year, yielding an

Discussion

The study findings indicate that specific domains that comprise high parent-reported quality of primary care for children are associated with lower subsequent nonurgent and urgent visit rates to the ED. High-quality family centeredness, timeliness, and realized access were all associated with lower subsequent nonurgent utilization of the ED for children, while high-quality timeliness and realized access were also associated with a lower subsequent urgent visit rate to the ED.

The findings from

Conclusions

Parent-reported high-quality timeliness, family centeredness, and realized access of primary care for a child are associated with significantly lower rates of subsequent nonurgent ED visits while high-quality realized access and timeliness are also associated with lower rates of urgent ED visits. Whether the ED visits are parent reported or are based on administrative data, the relationship between these domains of care and subsequent utilization is similar, thus strengthening the argument that

Acknowledgments

This work was supported by a grant (K08 HS015482-01A1) to Dr Brousseau from the Agency for Healthcare Research and Quality. The authors report no conflicts of interest or corporate sponsors.

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