emergency department

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Work-Family Crunch: Parents Resort To ER To Get Kids Back Into Daycare

(Bob Reck via Compfight)

(Bob Reck via Compfight)

Some of the tension between work and family is inevitable. If your child comes down with the flu on the very day you’re supposed to give a major presentation, there’s just no way you can be everywhere you’re needed at the same time.

But a study just out in the journal Pediatrics shows that the discrepancy between the sick-child policies at many daycare centers and accepted medical wisdom could often make the work-family crunch harder than it has to be. (Meanwhile, a day-long White House “summit” today is looking at ways to ease that crunch for American parents, from promoting more flexible work schedules to paid maternity leaves.)

From the study’s press release:

Substantial proportions of parents chose urgent care or emergency department visits when their sick children were excluded from attending child care, according to a new study by University of Michigan researchers.

The study, to be published June 23 in Pediatrics, also found that use of the emergency department or urgent care was significantly higher among parents who are single or divorced, African American, have job concerns or needed a doctor’s note for the child to return.

Previous studies have shown children in child care are frequently ill with mild illness and are unnecessarily excluded from child care at high rates, says Andrew N. Hashikawa, M.D., M.S., an emergency physician at  C.S. Mott Children’s Hospital. This is the first national study to examine the impact of illness for children in child care on parents’ need for urgent medical evaluations, says Hashikawa.

In the study, 80 percent of parents took their children to a primary care provider when their sick children were unable to attend child care. Twenty-six percent of parents also said they had used urgent care and 25 percent had taken their children to an emergency room.

“These parents may view the situation as a socioeconomic emergency,” Dr. Hashikawa says.

He got interested in this topic, he told me, when he was a med student working in an ER, and one night, a family brought in children who looked fine, they just had a little bit of red in their eyes. “And it was midnight, and I asked them, ‘Why are you here?’ I was just so curious. And they said ‘Well, I’ve got to work, I’m not going to get paid, and I really need a doctor’s note for both my work and for my daycare so I can send them back.'”

A bit more of our conversation, lightly edited:

How much does daycare keep kids out unnecessarily?

There are different ways to look at it…A Maryland study showed that for every one appropriate exclusion (from daycare) approximately five or six were inappropriate exclusions. I did a study from a daycare provider standpoint: If we gave you a hypothetical scenario, how many of these kids would you send home that probably didn’t need to be excluded? It seemed that 57% of kids would be unnecessarily excluded at that point.

The American Academy of Pediatrics has guidelines on when children should actually be kept home, right? Continue reading

Obamacare Preview? Mass. Studies Find Some Hospital Use Stays Same

(firemind/flickr)

(firemind/flickr)

Today is an Obamacare milestone: the end of the first enrollment period for new insurance plans the health care law spawned. More than 6 million previously uninsured people have signed up for private plans and 4 million more for Medicaid, The New York Times reports.

Opposition and skepticism remain, the Times says.

Yet beneath the loud debate, the law is quietly starting to change the health care landscape. In Kentucky alone, more than 350,000 people — about 8 percent of the state’s population — have signed up for coverage. Insurers and medical providers are reporting steady demand from the newly covered for health care, ranging from basic checkups to complex surgical procedures.

As that landscape changes, now seems a good time for a couple of reality-check studies from Massachusetts (yes, the state website has been messed up, but we did go through the current Obamacare stage of new enrollments years ago). They find that in certain ways — emergency room usage and readmission rates — expanded insurance coverage may not change health care, at least not immediately.

A study just out today in the medical journal BMJ finds that increasing health coverage does not quickly bring down readmissions — those unfortunate cases of patients who quickly bounce back into the hospital soon after being discharged. The hope is that having insurance and thus regular medical care will reduce those expensive readmissions. From the press release:

Boston—In a first of its kind retrospective study, Boston University School of Medicine researchers have found that providing health insurance coverage to previously uninsured people does not result in reducing 30-day readmission rates. The study, which appears in the British Medical Journal, used data on actual (versus self-reported) use of care and also found no change in racial/ethnic disparities in this outcome, despite a markedly higher baseline of uninsured among African-Americans and Hispanics in Massachusetts.

According to the researchers there are several possible explanations for their findings. For example, following health reform in Massachusetts, newly insured individuals were more able to seek medical attention after a hospital admission, which in turn may have uncovered medical problems requiring readmission. Another reason may be the inability to access a personal doctor in the state due to the primary care physician shortage, which has been well documented since 2006.

Other studies in Massachusetts have shown that access to care improved less than access to insurance, as many newly insured residents who obtained Medicaid or state subsidized private insurance still reported cost-related access barriers.

The conclusion: Expanding insurance coverage isn’t enough. Dr. Karen Lasser of the Boston University School of Medicine, the paper’s lead author, emailed that we also need to “reduce financial access barriers to care (e.g. copays), increase reimbursement rates for new insurance plans (so that more physicians accept these forms of insurance), implement medication reconciliation and patient coaching, improve disease management and coordination of care, and provide hospital based incentives to reduce use of inpatient services. Interventions could also tackle the shortage of primary care providers in MA.”

Meanwhile, another recent study, released last week, reported that, contrary to hopes that increased insurance coverage would cut expensive emergency-department use, the Massachusetts experience is that ER use slightly rose after health are reform. Continue reading

Emergency Department Visits Down For First Time Since Health Reform, Survey Finds

One of the key goals of health reform here in Massachusetts was to improve people’s health through prevention and primary care to the point that costly trips to the emergency room would decline. Until now, that hasn’t happened, according to several earlier reports.

But a just-released analysis, by the Blue Cross Blue Shield of Massachusetts Foundation found, for the first time, that ER visits (among non-elderly adults) have started to drop. Here, according to the report, which is also published in the current issue of the journal Health Affairs are the numbers:

Between fall 2006 and fall 2010, there were reductions in emergency department use overall (down 3.8 percentage points), frequent emergency department visits (down 1.9 percentage points), and the use of the emergency department for non-emergency conditions (down 3.8 percentage points). This is the first reduction in emergency department use among nonelderly adults in Massachusetts observed in the MHRS.

The reduced reliance on the emergency department among nonelderly adults may reflect many factors, including the increases in use of other types of health care (e.g., increases in preventive care visits, multiple doctor visits, specialist visits, and dental care) or increases in cost sharing under their health plans.

I asked John McDonough, Professor of Public Health Practice & Director of the Center for Public Health Leadership at the Harvard School of Public Health for his thoughts on the apparent drop in emergency department visits. Here’s his email response:

First, on the face of it, it’s good news to see ED use going down after so many years of no changes, and especially because that was an outcome many expected out of MA health reform. We expected this to happen, and when it did not, many were puzzled, and many used the non-drop as evidence of health reform’s failure.

Second, given the time lag, it’s not clear this most recent drop is because of MA health reform or because of other factors. Continue reading