a b s t r a c t

Background: Disparities exist in the care children receive in the emergency department (ED) based on their insur- ance type. It is unknown if these differences exist among children transferred from outside EDs to pediatric ter- tiary care EDs.

Objective: To compare reasons for transfer and services received at pediatric tertiary care EDs between children with private and public insurance.

Methods: We performed a secondary analysis of a multicenter survey of ED providers transferring patients to pe- diatric tertiary care EDs in three major U.S. cities. Risk differences (RD) and 95% confidence intervals (CI) were calculated to compare reasons for transfer and care received at pediatric tertiary care EDs based on Insurance type.

Results: There were 561 surveys completed by transferring providers describing reasons for transfer to pediatric tertiary care EDs with 52.2% of patients with private insurance and 47.8% with public insurance. We found no sig- nificant differences between privately and publicly insured children in reason for transfer for subspecialty con- sultation or need for admission. We found no significant differences in frequency of admission, radiologic studies, or ED procedures at the receiving facilities. However, a greater proportion of privately insured children had a subspecialty consultation at receiving facilities compared to publicly insured children (RD 9.7, 95% CI 2.0 to 17.4).

Conclusions: Transferred pediatric patients with private insurance were more likely to have subspecialty consul- tations than children with public insurance. Further studies are needed to better characterize the interplay be- tween patients’ insurance type and both the request for, and the provision of, ED subspecialty consultations.

(C) 2017

Background

Having adequate insurance improves access to health care for chil- dren [1]. Studies have shown that children with public insurance, or

? Source of support: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

?? Prior presentation: This study was presented at the Pediatric Academic Society

Annual Meeting in San Francisco, CA in May 2017.

* Corresponding author at: Boston Children’s Hospital, Division of Emergency Medicine, 300 Longwood Avenue, BCH 3066, Boston, MA 02115, USA.

E-mail addresses: [email protected] (C.A. Rees), [email protected] (S. Pryor), [email protected] (B. Choi), [email protected] (M.V. Senthil), [email protected] (N. Tsarouhas),

[email protected] (S.R. Myers), [email protected] (M.C. Monuteaux), [email protected] (R.G. Bachur), [email protected] (J. Li).

no health insurance at all, are less likely to receive primary care than children with private insurance [2]. Federally funded programs such as Medicaid and the Children’s Health Insurance Program have expand- ed coverage to many previously uninsured and under-insured children. In so doing, some Pediatric populations have become more likely to uti- lize their primary care providers and less likely to visit emergency de- partments (EDs) for their Health care needs [3].

Nevertheless, as many as 25% of children with public insurance, 16% of uninsured children, and 13% of children with private insurance visit an ED each year in the United States [4]. The care that children receive once in the ED varies by insurance status. Children with private health insurance are more likely to be admitted from the ED than children with public or no insurance [5,6]. Once hospitalized, children without insurance have increased all-cause mortality compared to children with either public or private insurance [7].

http://dx.doi.org/10.1016/j.ajem.2017.07.048

0735-6757/(C) 2017

1908 C.A. Rees et al. / American Journal of Emergency Medicine 35 (2017) 1907-1909

It is not known if differences exist surrounding reasons for transfer or the care received at pediatric tertiary care EDs for children who are transferred from an ED to a pediatric tertiary care ED based on patients’ insurance type. Elucidating disparities in reasons for transfer and care at receiving facilities is the first step in moving toward equitable health care for patients, regardless of their insurance type or status. The objec- tive of this study was to describe potential differences by insurance type in reasons for transfer and the care received in pediatric tertiary care EDs.

Materials and methods

We performed a secondary analysis of a multicenter study evaluat- ing reasons for interfacility transfer and care at receiving pediatric ter- tiary care EDs [8]. A more extensive description of this study’s methodology has been published previously [8]. In short, we sent a sur- vey to providers who transferred a pediatric patient to one of three pe- diatric tertiary care EDs to assess reasons for patient transfer. We subsequently reviewed these patients’ charts to extract insurance sta- tus, disposition, and services at the receiving facilities. We defined pub- lic insurance as being state or federally funded, while private insurance type was defined as those that do not receive state or Federal funding. To assess for potential enrollment bias, we used the same data abstraction tool that was used for our medical record review. This review encompassed the charts of selected patients who were transferred, yet did not have an accompanying provider survey; this group was defined as nonresponders. These charts were selected through a random num- ber generator. The study was approved by each site’s institutional re- view board. One of the hospitals included in the original study was excluded from this secondary analysis, as insurance status was not available for Transferred patients. Uninsured patients were not included in this analysis due to low frequency (n = 28).

We calculated risk differences (RD) and 95% confidence intervals (CI) to assess differences in reasons for transfer and care received at pe- diatric tertiary care EDs between patients with private and public insur- ance. We had a 91% power to detect a 10% difference, assuming a baseline proportion of 10%. Assuming a more common outcome, we were only powered to detect a difference of 15%, assuming a baseline proportion of 25%. All statistics were computed using Stata Special Edi- tion 14.1 (Statacorp; College Station, TX).

Results

Over a 25-month period, there were 3537 emails sent to transferring providers, with 907 total surveys being completed and 839 of those in- cluding completed information describing transfers to pediatric tertiary care EDs (26% overall response rate). Patient age, diagnosis, rates of ra- diography, admission, and subspecialty consultation among the nonre- sponder group were similar to the respondent group [8]. Of the 839 completed surveys with subsequent chart review, 561 included the pa- tients’ insurance type, with 52.2% of patients having private insurance and 47.8% of patients with public insurance. Among the nonresponder sample (n = 67), 47.7% were privately insured and 53.7% were publicly insured. Three hundred and ninety two of the 561 completed surveys

included information on providers’ primary work setting. Of those, 75.3% worked primarily in general emergency departments and 20.4% in pediatric emergency departments.

Overall, we did not find any significant differences between private- ly and publicly insured children being transferred for subspecialty con- sultation of any type or perceived need for admission of any type (Table 1). However, a greater proportion of privately insured children were transferred with the request to be seen specifically by a surgical subspe- cialist, when compared to publicly insured patients (RD: 8.1, 95% CI: 0.3 to 15.8). Also, a smaller proportion of privately insured children were transferred for the perceived need of a non-ICU regular inpatient care unit admission, when compared to publicly insured children (RD:

-6.7, 95% CI: -12.8 to -0.7).

In regards to outcomes and services provided at the receiving facili- ty, there were no significant differences in frequency of admission of any type, radiologic study, or ED procedures (Table 2). However, a greater proportion of privately insured patients had a subspecialty con- sultation at the receiving facility, compared to publicly insured patients (RD 9.7, 95% CI 2.0 to 17.4). Also, a smaller proportion of privately in- sured children were admitted to the pediatric intensive care unit when compared to publicly insured children (RD - 4.1, 95% CI - 7.9 to -0.4).

Discussion

To our knowledge, this is the first study assessing the influence of in- surance type on reasons for transfer and the care received at pediatric tertiary care EDs. Previous studies have shown that most pediatric emergency care occurs in general EDs [9,10], but fewer studies have de- scribed the reasons for transfer from general EDs to pediatric tertiary care EDs [8].

We found that publicly insured patients had a lower proportion of subspecialty consultations compared to privately insured patients. This is consistent with previous studies showing that children with pub- lic insurance (when compared with children with private insurance) are more likely to be undertriaged in the emergency department [11], receive less care in general in EDs [12-14] including advanced imaging for abdominal pain [15], and have less access to subspecialty care in the outpatient setting [16]. The decision to request subspecialty consul- tation in the pediatric ED is multi-factorial, and insurance type may be one contributing factor. Future studies assessing the decision-making process to consult subspecialists in the pediatric ED may further eluci- date how insurance type may influence providers’ decisions to request subspecialty consultation. In regards to reason for transfer, the reason- ing for a patient’s need for transfer is also multifactorial, and may be due to several factors, including ED physician Comfort level and local consultant’s recommendations.

Our study also found statistically significant differences by insurance type for children who were transferred with the request to be seen by a surgical subspecialist, perceived need for non-ICU regular inpatient care unit admission, and admission to the pediatric intensive care unit at the receiving facility. However, the confidence intervals for these findings approached zero in the setting of relatively small subgroups. Given the small sample size of these subgroups, further studies are warranted to

Table 1

Reasons for interfacility transfer to pediatric Tertiary care centers compared by patients’ insurance type.

Primary reason for transfer Private insurance, n = 293

Public insurance, n = 268

Risk difference 95% confidence interval

	n	%		n	%
Request to be seen by any subspecialist	201	68.6		164	61.2		7.4		-0.4, 15.3
Request to be seen by medical subspecialist	91	31.1		85	31.7		-0.6		-0.8, 7.0
Request be seen by surgical subspecialist	110	37.5		79	29.5		8.1		0.3, 15.8
Need for admission	52	17.7		64	23.9		-6.1		-12.9, 0.6
Need for admission to the non-ICU regular inpatient care unit	36	12.3		51	19.0		-6.7		-12.8, -0.7
Need for admission to the pediatric intensive care unit	16	5.5		13	4.9		0.6		-3.0, 4.3

C.A. Rees et al. / American Journal of Emergency Medicine 35 (2017) 1907-1909 1909

Table 2

Care received at pediatric tertiary care centers for patients transferred based on patients’ insurance type.

	Private insurance, n = 293 n	%		Public insurance, n = 268 n	%		Risk difference		95% confidence interval
Any subspecialty consultation	219	73.0		169	63.3		9.7		2.0, 17.4
Any radiologic study	127	42.3		109	40.8		1.5		-6.6, 9.6
Any ED physician procedure	40	13.4		30	11.2		2.1		-3.3, 7.5
Admission of any kind	170	56.7		163	61.0		-4.4		-12.5, 3.7
Admitted to non-ICU regular inpatient care unit	156	52.7		141	53.2		-0.5		-8.8, 7.8
Admitted to the pediatric intensive care unit	10	3.4		20	7.5		-4.1		-7.9, -0.4

evaluate these differences in reasons for transfer and care at receiving facilities by patient insurance type.

Other studies have shown that children with public insurance are less likely than children with private insurance to receive diagnostic imaging, have labs drawn, or have procedures performed for the same diagnosis [12,13,17]. Additionally, patients with public insur- ance are more likely to experience delays in receiving some proce- dures [14]. Our study evaluating the outcomes for children who were transferred from one facility to pediatric tertiary care EDs did not reveal these same disparities at the receiving facility. The differ- ence in our findings compared to previous studies may be due to children undergoing extensive diagnostic workups prior to being transferred to a pediatric tertiary care ED, leaving less evaluation to be done at receiving hospitals.

This study is subject to several limitations. For some relatively com- mon outcomes, this secondary analysis may have been under-powered to detect small effect sizes. Additionally, we were unable to compare reasons for transfer and care at receiving facilities by diagnostic groups within each insurance type, due to our sample size. Further investiga- tion evaluating potential subpopulations that may contribute to the ob- served disparities are warranted. Moreover, there is the possibility of referral bias based on insurance type during interfacility transfers. How- ever, our study group and our nonresponder sample group had similar proportions of publicly and privately insured patients, making this less likely.

Conclusion

Transferred pediatric patients with private insurance were more likely to have subspecialty consultations than children with public insurance. Though we found statistically significant differences based on patient insurance type for requests to be seen by a surgical subspecialists, requests for non-ICU regular in- patient care unit admissions, and pediatric intensive care unit ad- missions, the relevance of these findings is difficult to interpret given the small sample sizes. Differing patient demographics and variation in hospital practices may have contributed to some of the disparities in care received. Further studies are need- ed to better characterize the interplay between patients’ insur- ance type and both the request for, and the provision of, ED subspecialty consultations.

Acknowledgments

The authors would like to acknowledge Aderoke O. Adekunle-Ojo, MD for her assistance with this project.

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