Degree of Emergency Department use by children with spina bifida followed at a large, urban tertiary care hospital between 2016 - 2022 is associated with clinical complexity and non-white race
Sally Zimmermann, BA, Jacob C. Smith, MD, Teresa L. Russell, MS, Elena Johnston, BA, Ian McCarthy, BA, Bruce M. Sprague, BS, M. Sohel Rana, MBBS, MPH, Christina P. Ho, MD, Hans G. Pohl, MD, Briony K. Varda, MD, MPH.
Children's National Hospital, Washington, DC, USA.
BACKGROUND: The degree of Emergency Department use (EDU) by children with spina bifida (SB) is not well-characterized. We aimed to quantify the degree of EDU by children with SB followed at our institution, and to perform an adjusted analysis to identify any patient or clinic factors associated with degree of EDU. METHODS: We performed a retrospective cohort study of children ≤18 years old with SB continuously followed at our institution between 2016 - 2021. Baseline patient (age, sex, race, ethnicity, language, childhood opportunity index [COI] level, state of residence and distance to the ED) and clinical characteristics (type of dysraphism, lesion level, ambulation status, respiratory adjuncts, presence of ventricular shunt) were collected. EDU was characterized into 1) any EDU and 2) high EDU (>1 visit annually). Descriptive statistics and multivariable regression were performed for each outcome. Multiple imputation was used for missing data. RESULTS: Among 389 children, 834 ED visits occurred. Half (47%) had ≥1 visit and 15% had high EDU. The median EDU was 0.2 visits per person-year (range 0 - 8). A significantly larger proportion of non-white, Hispanic, Spanish-speaking, publicly insured children living a median 15 miles away presented to the ED. For high EDU, a significantly larger proportion of non-white, publicly insured patients living a median 10 miles away were represented. Clinical factors statistically more common in children with EDU and high EDU were suprasacral lesions, non-community ambulation status, ventricular shunt systems, and use of respiratory adjuncts. Multivariable analysis demonstrated increased odds of EDU based on state, race, ambulation status, shunt status and use of a respiratory adjunct. For high EDU, state of residence, distance to ED, ambulation status, and respiratory adjunct were associated (Table 1). Missing data ranged from 0-9% for each variable. CONCLUSIONS: About half of SB children had EDU at our institution, with 15% having multiple ED visits each year. Factors reflecting clinical complexity were associated with both any EDU and high EDU. After adjusting for these clinical characteristics, adverse social determinants of health, and proximity to the ED, non-white children with spina bifida continued to have 90% higher odds of using the ED than their white peers. 
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