Social risk factors associated with increased pediatric emergency department utilization

1. In a large cohort of children screened for risk factors such as food insecurity and housing instability in a primary care setting, those with positive risk factors were 18% more likely to have at least one emergency department visit within the study period.

2. Children with social risk factors were 36% more likely to be hospitalized.

Evidence Rating Level: 2 (Good)

Study Rundown: Emergency department (ED) use may serve as a marker for both illness and decreased access to outpatient primary and specialty care. This cohort study including approximately 4,700 children aimed to assess the effect of social risk factors, including food insecurity, housing instability, and caregiver substance use, on utilization of pediatric acute care, including both ED visits and hospitalizations. Notably, the study population was made up of children who had at least 3 primary care clinic visits within the study period, so this study includes only children with some connections to preventive care. Children with any social risk factors were 18% more likely to have an ED visit and 36% more likely to have a hospitalization during the study period. Positive screening in the primary care clinic for social risk factors was not significantly associated with time to first ED visit or hospitalization. Children with social risk factors also had higher rates of attention deficit hyperactivity disorder (ADHD), asthma, and prematurity than children without. The association of these conditions with poverty means that they may act as either confounders or mediators for the outcomes of ED visits and hospitalizations. This study shows that even among families connected to primary care and using the same healthcare system, social determinants of health are significantly associated with different patterns of healthcare utilization. It is difficult, however, to determine based on the reported data whether children with social risk factors in this cohort had more or more serious illnesses at baseline, were more likely to be brought to care later in an illness course, or some combination of the two.

Click to read the study in Journal of Pediatrics

Relevant Reading: Screening children for social determinants of health: A systematic review

In-Depth [retrospective cohort]: Patients attending the primary care clinic at a single large hospital in North Carolina between 2017 and 2021 were included. The population included 63% Hispanic patients and 21% Black patients. Screening for social risk factors was conducted using a parent questionnaire in the clinic and scored between 0 and 7; 40% of patients scored at least 1. Age, sex, race, and ethnicity all differed significantly between patients with and without risk factors. Nearly 9,000 ED visits and 559 hospitalizations took place during the study period. Cross-sectional multivariable modeling for associations between social risk factors and total number of ED visits or hospitalizations was performed. The incidence rate ratio (IRR) of 1.18 for ED use in patients with social risk factors had a 95% confidence interval (CI) of 1.12-1.23; for hospitalizations, the IRR was 1.36 (95% CI 1.26-1.47). A longitudinal time-to-event analysis was also performed with Cox proportional hazard regression to look for associations between risk factors and time to first ED visit or hospitalization.

Image: PD

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