This study examined LWCET among pediatric patients in a multi-center cohort of EDs in the upper Midwest. Overall, 1.7% of pediatric visits resulted in LWCET. While these rates of LWCET are relatively low compared to other hospital settings, [1, 13, 14] results from this study found that AI children were significantly more likely to LWCET compared to white patients, which merits further discussion. Other factors associated with increased odds of LWCET included less severe triage score, presenting to the ED during weekday hours, and ED activity level.
Previous studies have found that patients who live closer to the ED have higher odds of leaving prematurely [1, 14]. This was also seen in our study, where children who lived further than 5 miles from the ED have slightly lower odds of LWCET (OR = 0.86, CI = 0.76–0.98). The assumption for this may be that patients who live closer to the ED may be more likely to use ED services than seeking other medical care because it may be quicker or more accessible than other options. Similarly, these patients may also leave the ED without being seen because they can return if necessary.
As location of the site could have been a factor in racial differences and LWBS, we tested the interaction between site and race and found no significant relationship. One may assume that the reason for differences in AI children may be because they are visiting rural EDs that may have fewer resources and longer wait times, resulting in a higher rate of LWCET. However, no difference in LWCET was seen between sites, and a higher amount of LWCET in AI children was seen regardless of ED location.
Both MA insurance and race may be proxies for low socioeconomic status, and patients with MA insurance often use the ED as a substitute for primary care [5, 12]. A previous study found that patients with low-income and poor, or no insurance, were more likely to leave without being seen [15]. However, no significant association was seen between LWCET and insurance in our study. This suggests that other factors, including social or cultural may be of importance when exploring the reasons for why AI children LWCET, and could explain why we observed a different association between AI children and LWCET than we observed with AA children.
Unique to our study, we examined the relationship of LWCET and the ED activity level. As previous research suggests [1,2,3,4], our results showed a significant association with higher ED activity levels and increased odds of premature departure. This may be associated with time of arrival, as EDs are undoubtedly busier at varying times. We also found a significant association with time of arrival and LWCET. Patients who presented to the ED on weekdays between 10 pm and 7 am had odds of LWCET 1.43 times higher than patients who arrived during weekday business hours. Contrary to previous research [1], however, our study found a lower rate of LWCET during the weekends.
The strongest predictor of LWCET was race. Previous studies have also found racial disparities among patient wait times and LWCET in the ED [2, 3, 5, 7, 16, 17]. We observed a significant relationship between AI children and LWCET while accounting for potential confounding factors. In our study, AI children had 1.62 times higher odds of LWCET compared to White children, whereas no significant difference was observed for AA children compared to White children. A similar study by Bourgeois et al. (2008) also found that AI children had higher odds of LWCET than White children [12]. This persistent increase in LWCET among AI children indicates significant disparities in ED care in this disadvantaged population, and merits further investigation.
Discrimination, or perceived discrimination, may play a role [18]. One study indicated that AI parents were 25 times more likely to perceive racial discrimination in a health care setting than non-Hispanic White patients [19]. Several studies have noted minority patients are often assigned less urgent triage scores, have longer wait times, and are less likely to receive pain medications in ED settings [20,21,22]. This may be due, in part, to health care providers’ conflicting attitudes towards patients who use the ED for non-urgent conditions [23]. Many social determinants may factor into these use patterns and lead to overuse and lower quality care. Understanding use and care patterns among AI pediatric patients in the ED will result in a more comprehensive picture of health care in this population. Interventions to address issues of ED use and care could lead to substantially improved ED outcomes for AI children.
Strengths
This study had several strengths. The data encompasses five EDs with a larger proportion of AI children that allows us to look at patterns in LWCET in this specific minority group not currently explained within the literature. While limited by medical record data, we were still able to account for several confounders such as distance from ED, ED setting, timing of visit, and the level of traffic within the ED. The development of our ED activity level allows us to look more into the environment of the ED, while other studies have only focused on the day and time of visit without accounting for how busy the ED is at the time of visit.
Limitations
There are potential limitations to this study. First, these data may not be representative of the AI children outside of the Upper Midwest since many regional differences may affect the relationship between race and LWCET; therefore, no assumptions should be made about generalizability outside this region. Furthermore, while we did attempt to account for differences by site by including it as a random effect in our model, the diversity of each site may affect the results and the EDs included may not be a random sample of the population of EDs that serve AI children. Finally, medical record data did not allow us to determine at what point in the visit children LWCET or for what reason, therefore we are only able to suggest further exploration into this observed relationship to better inform possible intervention efforts.
