Rural-Urban Differences in Emergency Department Choice for Children With Medical Complexity, 2012-2017

Children with medical complexity (CMC) may bypass emergency departments (EDs) close to home to seek care at hospitals with more specialized pediatric services. However, few studies have examined ED choice for CMC or how this differs by rurality. This work describes rural-urban differences in ED care and bypass patterns, examines associations between ED bypass and visit outcomes, and identifies factors associated with ED bypass.

We analyzed 2012 to 2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire. Bypass was defined as a driving time of ≥5 minutes than time to the closest ED. We used logistic regression to identify factors associated with ED bypass and examine associations between bypass and rates of inter-facility transfer, index hospital admission, and in-hospital mortality.

In total, 82,747 CMC experienced 284,374 ED visits. Rural-residing CMC were more often insured by Medicaid, more likely to travel >30 minutes, and less likely to bypass their closest EDs (26.9% vs. 43.7% for urban-residing CMC). In adjusted regression models, ED bypass was associated with significantly increased odds of admission (OR=2.19, 95% CI: 1.51-3.16) but not with interfacility transfer or mortality. Chronic condition primary diagnosis was associated with increased odds of bypass, and Medicaid coverage was associated with decreased odds of bypass for both rural-residing and urban-residing CMC.

Rural-residing and urban-residing CMC differed in where they sought ED care and in their ED bypass patterns. These findings illustrate several factors that may be associated with ED choice for CMC and can inform clinical improvement efforts for this population.