561 - Rural-Urban Disparities in Emergency Department Visits for Children with Medical Complexity

Publication Number: 561.6303

Seneca D. Freyleue, Geisel School of Medicine at Dartmouth, Colchester, VT, United States; Mary Arakelyan, Children's Hospital at Dartmouth-Hitchcock, Lebanon, NH, United States; Andrew Schaefer, Geisel School of Medicine at Dartmouth, Hanover, NH, United States; Erika Moen, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States; A. James O'Malley, Geisel School of Medicine at Dartmouth, Hanover, NH, United States; David C. Goodman, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States; JoAnna Leyenaar, Dartmouth Health Children's, Lebanon, NH, United States

Background: Rural-residing children with medical complexity (CMC) have more emergency department (ED) visits than their urban-residing peers and many may bypass EDs close to home to seek care at centers with more specialized services. However, few studies have examined rural-urban differences in where CMC seek ED care or in their outcomes; this knowledge is important to address rural-urban disparities.

Objective: To characterize differences in ED use by rural- and urban-residing CMC including differences in patterns of ED bypass; identify associations between clinical, socioeconomic, and health system factors and ED bypass and between ED bypass and ED disposition; and determine if rurality modified these associations.

Design/Methods: We analyzed 2012-2017 all-payer claims data from Colorado, Massachusetts and New Hampshire. CMC were identified using the Pediatric Medical Complexity Algorithm and Complex Chronic Condition Classification System. The closest ED to each child's population-weighted ZIP code centroid was identified; ED bypass was defined as a driving time of 5 min or greater than time to the closest ED. We used logistic regression to identify factors associated with ED bypass and to examine associations between ED bypass and rates of inter-facility transfer, index hospital admission, and mortality.

Results: 82,747 CMC experienced 284,374 ED visits. Rural-residing CMC were more often insured by Medicaid, less likely to present with chronic condition primary diagnoses, more likely to travel >30 min for care, and less likely to be admitted at the index hospital (Table 1). Rural-residing CMC were less likely to bypass their closest EDs (26.9% vs 43.7% for urban CMC, standardized difference=0.36, Figure 1). Chronic condition primary diagnosis and ambulance transport were associated with increased odds of bypass, while Medicaid primary payer and dedicated pediatric resources at closest EDs were associated with decreased odds of bypass; rurality modified several of these effects (Table 2). In adjusted regression models, ED bypass was associated with two-times the odds of admission (OR=2.19, 95%CI:1.51-3.16) with no significant differences in mortality or transfer compared to non-bypass visits.

Conclusion(s): Several sociodemographic, clinical, and health system factors were associated with ED choice and associations differed for rural- and urban-residing CMC. Bypass was associated increased odds of hospitalization; ED choice may have been influenced by perceived admission needs. These findings illustrate the complexity of ED choice for CMC and can inform health policy and care coordination for this population.

Table 1. Characteristics of emergency department visits by rural- and urban-residing children with medical complexity and associated standardized differences
PAS 2025 ED Table 1.pdf

Table 2. Heterogeneity of treatment effect analysis, examining modification of the effect of clinical, sociodemographic, and health system factors on emergency department (ED) bypass by residential rurality1
PAS 2025 ED Table 2.pdf

Figure 1. Alluvial plots for rural- and urban-residing children with medical complexity showing pediatric capabilities of hospitals closest to home (left), whether or not the closest hospitals were bypassed (center), and the pediatric capabilities of hospitals where emergency care was initially received (right)
PAS 2025 ED Figure 1.pdf