Differences in Declines in Pediatric ED Utilization During the Covid19 Pandemic by Socioeconomic Disadvantage

  1. Bisakha Sen
  2. Anne Brisendine
  3. Pallavi Ghosh

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Abstract

Background

There is growing evidence that the early months of the COVID19 pandemic saw substantial declines in pediatric Emergency Department (ED) utilization in the U.S. However, less is known about whether utilization changed differentially for children who are socio-economically disadvantaged. We examined how changes pediatric ED visits during the early months of the COVID19 pandemic differed by two markers of socio-economic disadvantage, minoritized race and being publicly insured.

Methods

This retrospective observational study used electronic medical records from a large pediatric ED in a Deep South state for January-June 2020. Three time-periods ╌ pre-COVID19 (TP0), COVID19 with restrictions like stay-at-home (TP1), and COVID19 with restrictions relaxed (TP2) in 2020 were compared with the corresponding time-periods in 2019. Changes in overall visits, visits for minoritized race (MR) versus non-Hispanic white (NHW) children, and Medicaid-enrolled versus privately-insured children were considered, and changes in acuity-mix of ED visits and share of visits resulting in inpatient admits were inspected.

Results

Compared to 2019, total ED visits declined in TP1 and TP2 of 2020 (54.3%, 48.9%). Declines were larger for MR children (57.3%, 57.8%) compared to NHW children (50.5%, 39.3%), and Medicaid enrollees (56.5%, 52.0%) compared to the privately insured (48.3%, 39.0%). Particularly, MR children saw steeper percentage declines in high-acuity visits and visits resulting in inpatient admissions compared to NHW children. The mix of pediatric patients by race and insurance-status, as well as the share of high-acuity visits and visits with inpatient admissions differed between TP1 and TP2 of 2019 and 2020 (p<0.05 for all cases). In contrast, there was little evidence of difference between TP0 of 2019 and 2020.

Conclusion

The role of socioeconomic disadvantage and the potential impacts on pediatric ED visits during COVID19 in the Deep South of the United States changes is understudied. We find evidence of steeper declines in visits among MR and Medicaid-enrolled children, including for high-acuity conditions, than their NHW and privately-insured counterparts. Since disadvantaged children sometimes lack access to a usual source of care, this raises concerns about unmet health needs, and worsening health disparities, in a region that already has poor health indicators.

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  1. ScreenIT

    SciScore for 10.1101/2021.04.09.21255225: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: The study protocol was approved by the Institutional Review Board of [BLINDED FOR REVIEW – University name and IRB Registration Number] as exempt.
    Consent: No informed consent was obtained for the study as the data were retrospective medical records and were de-identified prior to receipt by the authors.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    All analyses were completed using STATA version 16.
    STATA
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    We acknowledge several limitations. First, we derived our information from patient EMR data provided by the ED, hence we did not have information on reasons why patients decided to not come to the ED, whether urgent care was delayed, and whether there were subsequent adverse health consequences of the delay. Nor did we know whether and to what extent patients were able to access alternate sources of care – such as in-person or telehealth visits with healthcare providers for low acuity conditions, or direct inpatient admission arranged by healthcare providers for higher acuity conditions. Second, the Hispanic population in the state and in our sample was small, which precluded us from examining Hispanic patients as a separate category in our analyses. Third, we did not go beyond acuity-level and categorize exactly what health conditions patients were presenting with, since that has been exhaustively categorized in the multi-state studies. Fourth, while we separated our time period into the time when various state-level restrictions were in place versus not, we cannot ascribe causal impacts of the restrictions – for example, it could be speculated that the partial rebound that we saw among NHW patients was because NHW populations became less apprehensive about the virus within a few months than MR populations. Finally, while our study makes the important contribution of presenting information from a Deep South state ED, results may not be generalizable to the entire country. In...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2021.04.09.21255225v1 on medRxiv