1. Emergent and Non-Emergent Visits to a Children’s Hospital’s Emergency Department Between 1987 and 2003 John Pascoe 1, Adrienne Stolfi 1, Arthur Pickoff 1, Carla Clasen 2, Katherine Cauley 2 1 Department of Pediatrics and 2 Center for Healthy Communities, Wright State University, Dayton, Ohio ABSTRACT RESEARCH OBJECTIVE: To examine the annual proportions of emergent/non-emergent visits to a children's hospital Emergency Department over 17 years (1987-2003). STUDY DESIGN: The Emergency Department Profiling Algorithm created by John Billings, M.D. and his colleagues at the New York University Center for Health and Public Service Research was applied to the administrative records of all children seen at The Children's Medical Center of Dayton's Emergency Department (ED) from 1987-2003. The four algorithm categories included: Non-Emergent, Emergent/Primary Care Treatable, Emergent/ED Care Needed but Preventable, and Emergent/ED Care Needed, Not Preventable. The algorithm was developed by a panel of emergency department physicians and is based on information abstracted from a total of 5700 emergency department records of children and adults from six Bronx, New York hospitals in 1994 and 1995. For each diagnosis a specific proportion of patients was assigned to each of the four categories noted above, thus the sum of the proportions for each diagnosis equals 100%. POPULATION: There were 717,355 visits to the Emergency Department at The Children's Medical Center of Dayton for children less than 19 years old between 1987 and 2003 and 461,796 visits "mapped" to the algorithm. FINDINGS: The most common Emergency Department diagnoses that "mapped" to the algorithm were otitis media (64,199), asthma (42,306), acute URI (40,692), fever (39,878) and gastroenteritis (33,043). The overall mean+/-standard deviation (SD) of proportions for each of the algorithm's four categories over 17 years: Non-Emergent.35+/-.27, Emergent/Primary Care Treatable.36+/-.25, Emergent/ED Care Needed, but Preventable.17+/-.31, Emergent ED Care Need, Not Preventable.12+/.21. The proportion of Non-Emergent visits ranged from.29 to.37 between 1987 and 1996. The State Child Health Insurance Plan was enacted by Congress in 1997 and the proportion of Non-Emergent visits dropped to.25 in 1997,.26 in 1998 and.30 in 1999. Between 2000 and 2003 Non-Emergent visits ranged from.37 to.45. During the same interval (1997-2003) Emergent visits, Not Preventable ranged from.10 to.17. Total ED visits at The Children's Medical Center of Dayton that "map" to the algorithm have almost doubled between 1987 (n=17269) and 2003 (n=32504) while total ED visits have increased from 29913 (1987) to 46834 (2003). CONCLUSION: Children with common primary care diagnoses (e.g., otitis media, acute URI) are often seen at The Children's Medical Center of Dayton's Emergency Department. Mean Non- Emergent visits (.35) for children less than 19 years are less common in Dayton compared to Non- Emergent visits to New York emergency departments (.42) as reported by Dr. Billings in 1998. Emergent Visits/Not Preventable were similar for Dayton (.12) and New York (.15). There was a temporal association between enactment of the State Child Health Insurance Program and a decrease in Non-Emergent visits for two to three years. However, Non-Emergent visits have risen during the last several years to more typical levels. IMPLICATIONS: Emergency department physicians at The Children's Medical Center of Dayton have provided health care to thousands of children over many years for non-emergent conditions. The State Child Health Insurance Plan has not resulted in permanent change to fewer Non- Emergent visits. While improving access to the primary care delivery system for children and adolescents is a complex task, it is a vitally important component of any comprehensive strategy that aims to provide high quality, cost effective medical care for children and adolescents in the 21st century. RESEARCH OBJECTIVE To examine the annual proportions of emergent/non-emergent visits to a children's hospital emergency department over a 17-year period (1987-2003). CONCLUSIONS Children with common primary care diagnoses (e.g., otitis media, acute URI) are often seen at The Children's Medical Center of Dayton's ED. Mean Non-Emergent visits (.35) for children less than 19 years are less common in Dayton compared to Non- Emergent visits to New York emergency departments (.42) as reported by Billings. Emergent Visits/Not Preventable were similar for Dayton (.12) and New York (.15). There was a temporal association between enactment of the State Child Health Insurance Program and a decrease in Non-Emergent visits for two to three years. However, Non-Emergent visits have risen during the last several years to more typical levels. RELEVANCE Emergency department physicians at The Children's Medical Center of Dayton have provided health care to thousands of children over many years for non-emergent conditions. The State Child Health Insurance Plan has not resulted in permanent change to fewer Non-Emergent visits. While improving access to the primary care delivery system for children and adolescents is a complex task, it is a vitally important component of any comprehensive strategy that aims to provide high quality, cost effective medical care for children and adolescents in the 21st century. STUDY DESIGN The Emergency Department Profiling Algorithm created by John Billings, J.D. and colleagues at NYU Center for Health and Public Service Research was applied to the administrative records of all children seen at The Children's Medical Center of Dayton's Emergency Department (ED) from 1987-2003. Emergency Department Profiling Algorithm: Developed by a panel of ED physicians. Based on information abstracted from 5700 ED records from six Bronx, NY hospitals in 1994-1995. Includes four algorithm categories: Non-Emergent, Emergent/Primary Care Treatable, Emergent/ED Care Needed but Preventable, and Emergent/ED Care Needed, Not Preventable. For each diagnosis a specific proportion of a visit is assigned to each of the four categories noted above, thus the sum of the proportions for each diagnosis equals 100%. POPULATION: There were 717,355 visits to the Emergency Department at The Children's Medical Center of Dayton for children less than 19 years old between 1987 and 2003. Of these, 461,796 (64.4%) visits "mapped" to the algorithm. Emergent Primary Care Treatable ED Care Needed Not preventable/avoidable Preventable/avoidable Non-Emergent Source: NYU Center for Health and Public Service Research NYU ED Algorithm: http://www.wagner.nyu.edu/chpsr/index.html?p=60 NYU ED CLASSIFICATION ALGORITHM PRINCIPAL FINDINGS  The total number of ED visits for children <19 years old at The Children's Medical Center of Dayton increased from 29913 in 1987 to 46834 in 2003.  The proportions of visits that were Emergent/ Not preventable ranged from 0.08  0.18 to 0.17  0.29 over the 17-year period.  From 1987 to 2003, the number of visits that "mapped" to the NYU ED algorithm almost doubled, from 17269 in 1987 to 32504 in 2003. Figure 1. Overall ED use profile from 1987-2003. The means  standard deviations (SD) of the proportions for each of the algorithm's four categories over 17 years were: Non-Emergent 0.35  0.27, Emergent/ Primary Care Treatable 0.36  0.25, Emergent/ED Care Needed, but Preventable 0.17  0.31, Emergent/ED Care Need, Not Preventable 0.12  0.21. Figure 2. The proportion of Non-Emergent visits before (1987-1996) and after (1997-2003) enactment by Congress of the State Child Health Insurance Plan. In 1987-1996 Non-Emergent visit proportions ranged from 0.29 to 0.37. Non-Emergent visits dropped in 1997 (0.25), 1998 (0.26) and 1999 (0.30), but then rose again between 2000 and 2003, ranging from 0.37 to 0.45. Table 1. The most common Emergency Department diagnoses that "mapped" to the algorithm during 1987-2003 were otitis media, asthma, acute URI, fever, and gastroenteritis. These diagnoses accounted for 47.7% of all mapped ED visits. RESEARCH FUNDED BY: HealthLink Miami Valley, Dayton, Ohio (A Healthy Community Access Program of the Health Resources and Services Administration)