Dayal Parul, Ruttan Timothy K, Kissee Jamie L, Sigal Ilana S, Marcin James P
From the Department of Pediatrics.
Department of Emergency Medicine, University of California Davis Health System, Sacramento, CA.
Pediatr Emerg Care. 2020 Sep;36(9):e500-e507. doi: 10.1097/PEC.0000000000001352.
The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED).
In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings.
Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results.
In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.
使用紧急医疗服务（EMS）对危重症儿童可挽救生命，且应根据儿童的临床需求来确定。我们的目的是确定非临床人口统计学因素和保险状况是否与前往急诊科（ED）就诊的儿童使用EMS有关。
在这项使用国家医院门诊医疗调查的横断面研究中，我们纳入了2009年至2014年前往急诊科就诊的儿童。我们使用多变量逻辑回归评估了EMS使用与患者保险状况之间的关联，并对人口统计学、社会经济和临床因素进行了调整，如通过修订和重新校准的《儿科急诊评估工具修订版》（mRePEAT）测量的疾病严重程度以及合并症或慢性病的存在情况。进行倾向得分分析以验证我们的研究结果。
在估计前往急诊科就诊的191,299,454名儿童中，11,178,576名（5.8%）通过EMS抵达，171,145,895名（89.5%）通过其他方式抵达。通过EMS抵达的儿童病情更严重[mRePEAT评分，1.13；95%置信区间（CI），1.12 - 1.14，而mRePEAT评分，1.01；95% CI：1.01 - 1.02]，并且更有可能患有合并症或慢性病（OR：3.17，95% CI：2.80 - 3.59）。在调整分析中，与有私人保险的儿童相比，无保险儿童使用EMS的几率更高，有公共保险的儿童使用EMS的几率更低[OR（95% CI）：无保险，1.41（1.12 - 1.78）；公共保险，0.77（0.65 - 0.90）]。倾向得分分析显示了类似的结果。
与成年患者不同，即使在调整疾病严重程度和其他混杂因素后，有公共保险的儿童使用EMS的可能性仍低于有私人保险的儿童。
