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      Predictors of emergency department use by adolescents and adults with autism spectrum disorder: a prospective cohort study

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          Abstract

          Objectives

          To determine predictors of emergency department (ED) visits in a cohort of adolescents and adults with autism spectrum disorder (ASD).

          Design

          Prospective cohort study.

          Setting

          Community-based study from Ontario, Canada.

          Participants

          Parents reported on their adult sons and daughters with ASD living in the community (n=284).

          Main outcome measures

          ED visits for any reason, ED visits for medical reasons and ED visits for psychiatric reasons over 1 year.

          Results

          Among individuals with ASD, those with ED visits for any reason were reported to have greater family distress at baseline (p<0.01), a history of visiting the ED during the year prior (p<0.01) and experienced two or more negative life events at baseline (p<0.05) as compared with those who did not visit the ED. Unique predictors of medical versus psychiatric ED visits emerged. Low neighbourhood income (p<0.01) and living in a rural neighbourhood (p<0.05) were associated with medical but not psychiatric ED visits, whereas a history of aggression (p<0.05) as well as being from an immigrant family (p<0.05) predicted psychiatric but not medical emergencies.

          Conclusions

          A combination of individual and contextual variables may be important for targeting preventative community-based supports for individuals with ASD and their families. In particular, attention should be paid to how caregiver supports, integrative crisis planning and community-based services may assist in preventing or minimising ED use for this vulnerable population.

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          Most cited references40

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          Trends and characteristics of US emergency department visits, 1997-2007.

          Ning Tang, John Stein, Renee Hsia … (2010)
          The potential effects of increasing numbers of uninsured and underinsured persons on US emergency departments (EDs) is a concern for the health care safety net. To describe the changes in ED visits that occurred from 1997 through 2007 in the adult and pediatric US populations by sociodemographic group, designation of safety-net ED, and trends in ambulatory care-sensitive conditions. Publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 through 2007 were stratified by age, sex, race, ethnicity, insurance status, safety-net hospital classification, triage category, and disposition. Codes from the International Classification of Diseases, Ninth Revision (ICD-9), were used to extract visits related to ambulatory care-sensitive conditions. Visit rates were calculated using annual US Census estimates. Total annual visits to US EDs and ED visit rates for population subgroups. Between 1997 and 2007, ED visit rates increased from 352.8 to 390.5 per 1000 persons (rate difference, 37.7; 95% confidence interval [CI], -51.1 to 126.5; P = .001 for trend); the increase in total annual ED visits was almost double of what would be expected from population growth. Adults with Medicaid accounted for most of the increase in ED visits; the visit rate increased from 693.9 to 947.2 visits per 1000 enrollees between 1999 and 2007 (rate difference, 253.3; 95% CI, 41.1 to 465.5; P = .001 for trend). Although ED visit rates for adults with ambulatory care-sensitive conditions remained stable, ED visit rates among adults with Medicaid increased from 66.4 in 1999 to 83.9 in 2007 (rate difference, 17.5; 95% CI, -5.8 to 40.8; P = .007 for trend). The number of facilities qualifying as safety-net EDs increased from 1770 in 2000 to 2489 in 2007. These findings indicate that ED visit rates have increased from 1997 to 2007 and that EDs are increasingly serving as the safety net for medically underserved patients, particularly adults with Medicaid.
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            International perspectives on emergency department crowding.

            Jesse M. Pines, Joshua A. Hilton, Ellen J Weber … (2011)
            The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes. © 2011 by the Society for Academic Emergency Medicine.
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              Parental report of health conditions and health care use among children with and without autism: National Survey of Children's Health.

              James G. Gurney, Melissa L McPheeters, Matthew Davis (2006)
              To compare parent-reported prevalence of health conditions and health care use between children with and without autism. Cross-sectional analysis of the 2003 to 2004 National Survey of Children's Health. Population-based sample across the United States. More than 100 000 parents. The main exposure was "autism" (not further defined), from response to the question: "Has a doctor or health professional ever told you that your child has autism?" Medical and mental health conditions and measures of health care use. Autism prevalence among children aged 3 to 17 years was 53 per 10 000 (95% confidence interval, 45-61 per 10,000), equating to a national estimate of 324 000 children (95% confidence interval, 274,000-375,000 children). Children with autism had a significantly (P<.001) higher prevalence of depression or anxiety problems (38.9% vs 4.2%) and behavioral or conduct problems (58.9% vs 5.2%) than children without autism. Respiratory, food, and skin allergies were reported by parents more often for children with autism, with food allergies having the strongest relative difference between the groups (odds ratio, 4.5; 95% confidence interval, 3.0-7.0). Children with autism had significantly (P<.001) higher mean physician visits over 12 months for preventive care, nonemergency care, and hospital emergency care, and were far more likely than children without autism to receive physical, occupational, or speech therapy (76.0% vs 6.3%), to need treatment or counseling for an emotional, developmental, or behavioral problem (75.4% vs 7.0%), and, among those taking a prescribed medication, to be using a medication long-term (51.4% vs 14.5%). We found markedly higher reports of concurrent conditions and health care use associated with childhood autism in this study.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2017
                Publication date (Electronic): 18 July 2017
                Volume: 7
                Issue: 7
                Electronic Location Identifier: e017377
                Affiliations
                [1 ] Centre for Addiction and Mental Health , Toronto, Canada
                [2 ] departmentDepartment of Psychiatry , University of Toronto , Toronto, Canada
                [3 ] departmentDepartment of Psychology , York University , Toronto, Canada
                [4 ] departmentDepartment of Psychology , University of Toronto Mississauga , Mississauga, Ontario, Canada
                [5 ] Research and Evaluation, Canadian Mental Health Association–Toronto Branch , Toronto, Canada
                Author notes
                [Correspondence to ] Dr Yona Lunsky; yona.lunsky@ 123456camh.ca
                Article
                Publisher ID: bmjopen-2017-017377
                DOI: 10.1136/bmjopen-2017-017377
                PMC ID: 5541491
                PubMed ID: 28720619
                SO-VID: 7a7ef941-dd1d-4f52-9ec3-d00918c360c7
                Copyright © © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 19 April 2017
                Date revision received : 15 May 2017
                Date accepted : 19 May 2017
                Funding
                Funded by: Canadian Institutes of Health Research;
                Categories
                Subject: Health Services Research
                Subject: Research
                Subject: 1506
                Subject: 1704
                Custom metadata
                special-feature unlocked

                ScienceOpen disciplines: Medicine
                Keywords: autism spectrum disorder,accident and emergency medicine,hospital
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: autism spectrum disorder, accident and emergency medicine, hospital

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