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The American Journal of Managed Care December 2013
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Characteristics of Low-Severity Emergency Department Use Among CHIP Enrollees
Justin Blackburn, PhD; David J. Becker, PhD; Bisakha Sen, PhD; Michael A. Morrisey, PhD; Cathy Caldwell, MPH; and Nir Menachemi, PhD, MPH
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Characteristics of Low-Severity Emergency Department Use Among CHIP Enrollees

Justin Blackburn, PhD; David J. Becker, PhD; Bisakha Sen, PhD; Michael A. Morrisey, PhD; Cathy Caldwell, MPH; and Nir Menachemi, PhD, MPH
Barriers to less resource-intensive settings may contribute to use of the emergency department for low-severity conditions.
Table 2 displays the characteristics of ED visits stratified by severity. Low-severity visits occurred more frequently in children aged 1 year and younger, 2 to 3 years, and 4 to 5 years; Caucasians; children with small rural and isolated residences; children who visited the ED on Sundays and Saturdays; and children who lived in areas with low utilization of appropriate well-child care. Low-severity visits occurred less often among children aged 12 to 19 years, males, African Americans, urban residents, children receiving management for a chronic disease, and children living in areas of high utilization of wellchild care.

Table 3 presents results from multivariate logistic models that investigated factors associated with low-severity visits. The reported risk differences represent percentage point differences in the fraction of low-severity ED patients who had a given characteristic (vs the referent) relative to high-severity ED patients. For example, the table presents evidence that low-severity ED patients were more likely to be younger than high-severity ED patients. The risk differences indicate that compared with children aged 0 to 1 year, children aged 2 to 3 years were 0.7 percentage points (95% CI, –1.4 to –0.1) less likely to have had a low-severity visit; children aged 4 to 5 years were 1.2 percentage points less likely (95% CI, –1.9 to –0.5); children aged 6 to 11 years were 2.7 percentage points less likely (95% CI, –3.4to –2.1); and children aged 12 to 19 years were 3.7 percentage points less likely (95% CI, –4.3 to –3.0). Low-severity ED patients were less likely to be male (1.4 percentage points; 95% CI, –1.8 to –1.1); to be African American (–1.5 percentage points; 95% CI, –1.9 to –1.1); to have a previously diagnosed chronic disease (10.3 percentage points; 95% CI, –10.7 to –9.9); and to live in an area with high compliance with appropriate well-child care (1.2 percentage points; 95% CI, –0.4 to –1.9). In contrast, lowseverity ED patients were more likely to be from isolated areas (1.6 percentage points; 95% CI, 1.0-2.2), and have visits on  Sunday (0.9 percentage point; 95% CI, 0.6-1.3) and Saturday(1.2 percentage points; 95% CI, 0.1-1.6). Although not presented here, results from the logistic regression model comparing intermediate- versus high-severity visits are included in the Appendix.


Using a pooled cross-sectional study of ED claims, we identified characteristics of low-severity ED patients in the Alabama CHIP, ALL Kids. Overall, we found that the majority of non–injury related ED visits were for low-severity conditions. Even though we cannot determine how many of these visits were unavoidable, some of the patterns we identified suggest that barriers to accessing other less resource-intensive sources of healthcare may contribute to use of the ED for low-severity visits. For example, we observed more use of the ED for lowseverity visits relative to high-severity visits on weekends and for rural patients; both findings may represent decreased access to primary care. In addition, children living in zip codes with the highest proportions of appropriate well-child visit rates (a proxy measure of access to primary care) had a lower likelihood of visiting the ED for a low-severity relative to a highseverity condition in the 12 years of data that we examined. Access to primary care is known to reduce low-severity ED utilization. Previous research has found that shortcomings in access to primary care8,25 or deficiencies in the quality of primary care6,8,9 contribute to low-severity ED use. Moreover, Halfon and colleagues12 previously found that primary care physician supply within a county influenced appropriate ED use behavior. The results of the current study, which focused on lowincome children, are consistent with this body of literature.

In our study, children with chronic diseases who utilized the ED were less likely to do so for low-severity visits than children without a chronic disease. This might be either because children with chronic diseases utilized the ED for reasons related to the underlying condition and as a result the visits were classified as more severe in nature, or because the increased contact with the healthcare system stemming from their chronic disease made them better consumers of appropriate resources. Children with chronic illnesses are known to use the ED with greater frequency than other children,26 but studies have not evaluated the severity of those visits. The primary chronic disease observed among children in ALL Kids was asthma. Although asthmatic episodes can be prevented through improved disease management,27 children experiencing symptoms need ED care and this is considered a high-severity visit by the Billings and colleagues17 algorithm and Wharam and colleagues method.18

Nonmodifiable characteristics such as sex and race were associated with differential patterns of ED use. Although some prior  studies have suggested that African Americans are more likely to use the ED for low-severity care,12,28 others have not.14 In the  current study, African American children who utilized the ED were less likely to do so for a low-severity ED visits compared with  children of other races. We also found hat female patients had a larger fraction of low-severity ED visits, which is consistent with previous work that identified females as using the ED for routine care more frequently.14 Lastly, we observed younger age groups  were associated with a larger share of low-severity ED visits than high-severity ED visits. Infants younger than 12 months of age  have the highest annual ED visit rate nationally,1 potentially due to the tendency of parents to err on the side of caution with newborns. 

The findings of this study should be interpreted in light of some limitations. First, claims data have inherent limitations for research or clinical purposes given that they are collected for administrative reasons.29 Second, ED claims in our study were categorized based on primary diagnosis only, and the algorithm for classifying visit severity based on diagnosis codes may have failed to capture all aspects of a child’s ED visit. Despite this, the methodologies of Billings and colleagues17 and Wharam and colleagues18 are reproducible and have been validated. If physicians make arbitrary decisions as to which diagnosis is listed first or second, then  misclassification of severity could have occurred. Third, the algorithms to classify ED visits may have limitations when applied exclusively to children, given that they were developed in a multiuse ED. Lastly, the results of this study should be generalized with caution to populations outside Alabama or CHIPs in general, especially when administered differently from ALL Kids.

Several factors are associated with the use of the ED for low-severity conditions among Alabama children enrolled in CHIP. However, some modifiable factors are reflective of limited utilization of, and possibly access to, quality primary care. Low-severity ED utilization may be reduced when primary care providers offer evening and weekend hours.6,8 Moreover, retail health clinics and urgent care centers, which utilize fewer resources than EDs, offer the potential to more efficiently treat low-severity conditions during off-hours.4 Policy makers may be able to reduce low-severity ED visits by encouraging expanded access to times and  locations that primary care services are provided.

Author Affiliations: From Department of Health Care Organization and Policy (JB, DJB, MAM, NM), University of Alabama at Birmingham, Birmingham, AL; Alabama Department of Public Health (CC), Bureau of Children’s Health Insurance, Montgomery, AL.

Funding Source: This work was supported by the Alabama Department of Public Health, Bureau of Children’s Health Insurance. The funding agency maintains the data used for this study, but the analysis and interpretation are the authors’ own.

Author Disclosures: The authors (JB, DJB, BS, MAM, CC, NM) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JB, DB, MAM, NM); acquisition of data (JB, NM); analysis and interpretation of data (JB, MAM,NM); drafting of the manuscript (JB); critical revision of the manuscript for important intellectual content (MAM, DB, BS, CC, NM); statistical analysis (JB); provision of study materials or patients (CC); obtaining funding (MAM, NM); administrative, technical, or logistic support (CC); and supervision (NM).

Address correspondence to: Justin Blackburn, PhD, 1665 University Blvd, Rm 330, Birmingham, AL 35294. E-mail:
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