Emergency Department Utilization by Adolescents in the United States

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Emergency Department Utilization by Adolescents in the United States

Amitai Ziv, MD*‡; Jack R. Boulet, PhD‡; and Gail B. Slap, MD*

ABSTRACT. Background. Adolescents in the United States have been shown to underutilize primary care services and therefore may rely heavily on emergency service. Although several small studies have explored local emergency services for youth, there are no pub-lished reports of adolescent utilization of emergency vices on a national scale. Furthermore, emergency ser-vices data have not been aggregated according to the age subgroups used by the current guidelines for adolescent care.

Objective. To explore the utilization of emergency departments in the United States by early (11 to 14 years), middle (15 to 17 years), and late (18 to 21 years) adoles-cent subgroups.

Design. Secondary analysis of the emergency depart-ment component of the 1994 National Hospital Ambula-tory Medical Care Survey.

Setting. Nationally representative sample of 418 emergency departments in the United States.

Patients. Approximately 26 547 visits by patients of all ages, representing 93.4 million total visits in 1994 and 14.8 million adolescent visits.

Outcome Measures. Number of visits, health insur-ance, reasons for visits, urgency of visits, resulting diag-noses, and hospitalization rates.

Results. Adolescents accounted for 15.4% of the pop-ulation and 15.8% of emergency department visits in 1994. Late adolescents were overrepresented in emer-gency department visits relative to their population pro-portion (6.8% of visits, 5.3% of population), whereas early adolescents were underrepresented (4.6% of visits, 5.9% of population). Lack of health insurance was more common among 11- to 21-year-olds (26.2%) than either children (13.6%) or adults (22.7%). By ages 18 to 21 years, 40.5% of male visits and 27.6% of female visits were uninsured. Injury-related visits were more common among adolescents (28.6%) than either children (23.1%) or adults (18.2%). Injury was the leading reason for visits among all adolescent age-sex subgroups (36.6% to 42.0% of male visits and 14.1% to 27.2% of female visits) except females aged 18 to 21 years for whom digestive reasons ranked first (18.8%). Injury was the leading diagnosis for all adolescent age-sex subgroups, with peaks at early adolescence of 61.6% for males and 45.8% for females. Across all adolescent age-sex subgroups, 3.1% to 5.3% of visits resulted in hospitalization, and 41.0% to 52.5% of

visits were urgent. These rates did not differ from those of children but were lower than those of adults.

Conclusions. Utilization of emergency departments increases and health insurance decreases during adoles-cence, suggesting that adolescents with inadequate health insurance may rely heavily on emergency depart-ments for their health care needs. Most adolescent visits to emergency departments are not urgent and might be better treated through nonemergency, primary care sites.

Pediatrics 1998;101:987–994; adolescents, utilization, emergency department, health insurance.

ABBREVIATION. NHAMCS, National Hospital Ambulatory Medical Care Survey.

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dolescent health status in the United States has drawn increasing attention in recent years. In 1990, the United States Congress commissioned a report on adolescent health by the Office of Technology Assessment.1 The resulting three-volume publication documented unacceptably high rates of adolescent morbidity and mortality from injury, homicide, suicide, violence, sexually transmitted disease, and pregnancy. Some of these crises might be preventable through health services that identify at-risk youth and provide effective in-tervention strategies. However, among adolescents, inadequate health insurance2– 4 and underutilization of primary care services5,6may translate into overde-pendence on emergency services for both crisis in-tervention and routine care.7–9 Furthermore, one re-port indicates that most visits to emergency departments by adolescents are made at night, when social services and community resources are least available.9 The emergency department staff caring for adolescents therefore confronts the simultaneous demands of high-severity crises, psychosocial com-plexity, health promotion, and disease prevention.

Few studies have described the characteristics of adolescent visits to emergency departments. Two retrospective reviews of adolescent emergency visits, one pertaining to an urban children’s hospital9and the other to a rural general hospital,8were based on small, locally-drawn samples. Their results therefore cannot be generalized nationally. Both studies report data for patients aged 12 to 18 years, without analy-ses by age subgroups. This approach, possibly uti-lized because of small sample sizes, does not allow for a description of trends during the course of ado-lescence in the number of visits, reasons for visits, or prevalence of health insurance. Although two na-tional data sets provide information on office visits by individuals aged 11 to 14 and 15 to 20 years,6 –10

From the *Craig-Dalsimer Program in Adolescent Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsyl-vania School of Medicine; and the Section of Adolescent Medicine, Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia; and the ‡Educational Commission for Foreign Medical Grad-uates (ECFMG), Philadelphia, Pennsylvania.

Received for publication Jul 10, 1997; accepted Oct 9, 1997.

Reprint requests to (A.Z.) Division of General Internal Medicine, Silverstein 3, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104.

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there seem to be no nationally representative sum-maries of emergency department visits.

The objective of this study was to analyze a large, nationally representative data set on emergency de-partment visits by adolescents in three age cohorts: 11 to 14 (early adolescence), 15 to 17 (middle adoles-cence), and 18 to 21 years (late adolescence). Recent guidelines for adolescent health care11,12have called for the specification of clinical services according to these subgroups to adjust for the changes in physi-ology, psychphysi-ology, and behavior that occur during the second decade of life.

The data for this report are derived from the 1994 National Hospital Ambulatory Medical Care Survey (NHAMCS) conducted by the Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention.13 This analysis focuses on that portion of the data pertain-ing to the adolescent population, with particular at-tention to visit number, health insurance, presenting complaint, and diagnosis.

METHODS Data Set

The NHAMCS is a national probability survey that provides data on ambulatory medical care rendered in hospital emergency and outpatient departments. The current study utilizes the emer-gency department component of the 1994 NHAMCS. The sample included 26 547 visits to 418 emergency departments made by patients of all ages. This represents a total of 93.4 million visits made in 1994 to hospital emergency departments in the United States.

The sampling unit for the NHAMCS was a standard patient record form utilized by all participating hospitals. The emergency department form included information about patient age, race, sex, ethnicity, health insurance, reason for the visit, diagnoses, procedures, and medications. A complete description of the NHAMCS has been published by McCraig and McLemore.14A general summary of the emergency department data for patients of all ages has been published by Stussman.13

The reason for the visit was derived from the patient’s descrip-tion of the problem on presentadescrip-tion to the emergency department. Each patient record could include up to three reasons. For the purpose of this analysis, only the principal reason, as judged by the health provider, was used. The principal reason was assigned a code by the NHAMCS based on published classification guide-lines.15This code then defined the general category to which the reason belonged.

The diagnoses were derived from the health-care provider’s diagnoses rendered at the completion of the visit and coded according to theInternational Classification of Diseases, 9th Revision, Clinical Modification.16The diagnosis corresponding to the princi-pal reason was used for the purpose of this analysis.

Census data was utilized to estimate the proportion of the United States population in each age, sex, and race cohort. This data came from theCurrent Population Survey: Personal Data Files.17

Statistical Analysis

Unlike simple random sampling, the four-stage probability design of the NHAMCS does not result in an equal chance of selection for each patient visit in the target population. Conse-quently, population characteristics must be estimated through the use of sampling weights that correct for the disproportionate representation.

The present analysis utilized the sample weights and a simple approximation to account for the effects of the sample design on the variance of the calculated estimates. These adjusted variance estimates, which take into account the clustering in the sample design, were used to calculate approximate standard errors. Al-though it is possible to compute more exact standard errors through resampling procedures,18this approach requires variables that were not available on the public-use date tapes.

Conse-quently, coefficients approximating the relative standard errors were used to adjust the variances of the patient-visit estimates.13 The SAS Statistical Software Package19 was used to derive the population estimates and approximate standard errors.

The public-use data tapes of the NHAMCS have strict release guidelines. Estimates with relative standard errors greater than 30% (sample size less than approximately 63 000 visits) are not reportable. Approximate standard errors for all reported estimates are given in all tables. Statistical tests comparing the proportions of a given population visit characteristic were performed by cal-culating the standard error of the difference and using the value to obtain at statistic. Because the standard errors are approxima-tions, exactPvalues are not reported. Instead,tvalues less than

22.3 or greater than12.3 were considered statistically significant (approximatePvalues less than .01).

RESULTS

Adolescent Visits to Emergency Departments

An estimated 14.8 million visits to emergency de-partments in the United States were made by ado-lescents aged 11 to 21 years in 1994. This represents 15.8% of visits made by individuals of all ages and closely matches the proportion of adolescents in the population (15.4% according to the 1994 Census).15 The match for ages 11 to 21 years masks, however, the underutilization relative to population propor-tion of emergency services by individuals aged 11 to 14 years and the overutilization by individuals aged 18 to 21 years (Table 1). Females comprised 50.9% of the 18- to 21-year-old population yet accounted for 55.0% of the visits made by this age group. This contrasts with early adolescence, when male visits predominated at 53.1% (Table 2). Black adolescents in all age groups were overrepresented in emergency department visits (21.0%) relative to their proportion of the population (15.7%). White adolescents com-prised 76.8% of visits and 79.3% of the population (Table 2).

Health Insurance

The expected sources of payment for adolescent visits to emergency departments in 1994 are summa-rized in Table 3. For these analyses, the NHAMCS data on health insurance were grouped into four categories: private insurance which includes visits expected to be paid fully or partially by private in-surance, commercial inin-surance, health-maintenance organizations, and/or other prepaid programs. Pub-lic insurance includes visits expected to be paid fully or partially by Medicare, Medicaid, and/or other government programs. Both of these categories ex-clude visits made by adolescents covered by both

TABLE 1. Emergency Department Visits, and Percent of Pop-ulation by Age Group

Age (y) No. of Visits (thousands)

Percent of Visits*

No. of Population† (Thousands)

Percent of Population†

,11 19 443 20.8 (0.3) 42 779 16.9

11–14 4308 4.6 (0.2) 14 876 5.9

15–17 4096 4.4 (0.2) 10 542 4.2

18–21 6372 6.8 (0.2) 13 336 5.3

22–44 33 162 35.5 (0.3) 92 132 36.4

45–64 13 011 13.9 (0.3) 48 942 19.4

.65 13 010 13.9 (0.3) 30 198 11.9

* Standard error is shown in parentheses.

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private and public insurance (,2% of adolescents). The category of no insurance includes visits made by adolescents with no evidence of either private or public insurance. These visits either were paid out-of-pocket, or no charges were levied.

The rates of no health insurance were signifi-cantly higher among adolescents aged 11 to 21 years (26.2%) than children younger than age 11 years (13.6%) (t 5 10.8, P , .01) or adults older than age 21 years (22.7%) (t 5 3.6, P , .01). For adolescents, lack of insurance increased from early to middle to late adolescence. By ages 18 to 21 years, 40.5% of male visits and 27.6% of female visits were uninsured (t54.5,P,.01). Within the 18- to 21 year-old age group, there were no signif-icant differences in uninsurance between black (24.5%) and white (28%) females or between black (42%) and white (40%) males. The rate of public insurance was higher among black than white ad-olescents for all age-sex subgroups (P , .01).

During early and middle adolescence, males and females did not differ significantly in their rates of uninsurance. However, between middle and late ad-olescence, female visits covered by private insurance declined (t 5 4.9, P , .01) and visits covered by public insurance increased (t53.9,P,.01). Between early and late adolescence, male visits covered by private (t54.5,P,.01) or public (t53.4,P,.01) insurance declined. This was associated with increas-ing rates of uninsurance between middle and late adolescents among males (t 5 5.9,P , .01) but not among females.

Urgency, Hospitalization, and Injury

The urgency of the visit and the rate of hospital-ization by age group and sex are shown in Table 4. A visit was defined as urgent if the patient required immediate attention for an acute illness or injury that threatened life or function. Across all adolescent age groups and both sexes, approximately one-half of the visits were not urgent and few visits (3.1% to 5.3%) resulted in hospitalization. The rate of hospitaliza-tion from emergency departments was lower (t 5 20.5,P,.01) for adolescents (4.6%) than adults aged 21 years and older (16.2%) but similar to that of children younger than age 11 years (5.4%). Adoles-cent males and females did not differ significantly in either the urgency of their visits (49% vs 41%) or their rates of hospitalization (4.1% vs 5.0%).

TABLE 2. Percentage of Emergency Department Visits and Population by Age Group, Sex, and Race*

Age (y) Male White† Black†

Visits Population‡ Visits Population‡ Visits Population‡

,11 54.3 (0.8) 51.5 74.0 (0.7) 78.5 22.6 (0.7) 16.3

11–14 53.1 (1.8) 50.7 76.4 (1.5) 79.0 21.4 (1.5) 15.9

15–17 49.6 (1.8) 51.0 76.9 (1.5) 78.7 21.8 (1.5) 16.2

18–21 45.0 (1.5) 49.1 77.1 (1.2) 79.9 20.3 (1.2) 15.2

22–44 47.7 (0.6) 49.4 75.2 (0.6) 82.3 22.0 (0.5) 12.7

45–64 46.6 (1.0) 48.3 79.6 (0.8) 85.9 17.8 (0.8) 10.2

.65 38.7 (1.0) 41.6 86.9 (0.7) 89.6 11.5 (0.7) 8.1

* Standard error is shown in parentheses.

† Other race categories are not presented because the data do not meet release criteria. ‡ Based on the 1994 Current Population Survey (census data).17

TABLE 3. Emergency Department Visits by Health Insurance Status, Age, and Sex*

Age (y) Private† Public‡ None§

Male Female Male Female Male Female

,11 39.3 (1.1) 34.8 (1.2) 45.3 (1.1) 49.4 (1.2) 13.5 (0.8) 13.8 (0.9)

11–14 56.5 (2.4) 48.4 (2.6) 25.7 (2.1) 28.7 (2.4) 16.3 (1.8) 21.2 (2.1)

15–17 55.5 (2.6) 48.2 (2.6) 20.7 (2.1) 27.4 (2.3) 23.1 (2.2) 22.7 (2.2)

18–21 41.8 (2.2) 32.3 (1.9) 16.8 (1.6) 38.9 (1.9) 40.5 (2.2) 27.6 (1.8)

22–44 42.2 (0.9) 41.9 (0.9) 20.4 (0.8) 30.5 (0.8) 36.7 (0.9) 26.4 (0.8)

45–64 51.1 (1.5) 52.9 (1.4) 25.5 (1.3) 25.3 (1.2) 21.1 (1.2) 19.4 (1.1)

.65 9.9 (1.0) 7.3 (0.7) 57.6 (1.6) 60.9 (1.3) 4.4 (0.7) 2.4 (0.4)

* Number is percentage of all visits made within the defined age-sex group. Standard error is shown in parentheses. Numbers within each age-sex group do not sum to 100 due to the small percentage of population with both private and public insurance.

† Private insurance includes private insurance, commercial insurance, health-maintenance organizations, and/or other prepaid programs. ‡ Public insurance includes Medicare, Medicaid, and/or other government programs.

§ No evidence of health insurance.

TABLE 4. Percentage of Emergency Department Visits by Age and Sex That Were Urgent and/or Resulted in Hospitaliza-tion*

Age (y) Urgent† Hospitalization‡

Male Female Male Female

,11 42.7 (1.1) 38.4 (1.2) 5.5 (0.5) 5.3 (0.6)

11–14 52.5 (2.5) 42.5 (2.6) 3.1 (0.9) 4.2 (1.1) 15–17 47.8 (2.6) 40.7 (2.5) 3.9 (1.0) 5.2 (1.1) 18–21 47.0 (2.2) 41.0 (2.0) 5.1 (1.0) 5.3 (0.9) 22–44 44.1 (0.9) 41.5 (0.9) 7.9 (0.5) 7.2 (0.5) 45–64 55.5 (1.5) 51.5 (1.4) 19.5 (1.2) 15.1 (1.0)

.65 64.4 (1.6) 64.4 (1.3) 38.9 (1.6) 36.5 (1.3) * Standard error is shown in parentheses.

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The rates of injury-related visits were higher dur-ing adolescence (28.6%) than durdur-ing childhood (23.1%) (t54.9,P, .01) or adulthood (18.2%) (t5 11.6,P,.01). Adolescent males were twice as likely as females to present to emergency departments for injuries (38.6% vs 19.1%, t5 11.4,P, .01), and the differences between male and female rates of injury-related visits were greater during adolescence than any other time of life (Table 5). The most common types of adolescent injury, each accounting for 1.7% to 3.7% of visits, were ankle and foot sprains, extrem-ity contusions and wounds, back sprain, and head and neck contusions and wounds.

Reasons for Visits and Diagnoses

The most common general reasons for adolescent visits to emergency departments by age group and sex are shown in Table 6. Injury was the leading reason in all subgroups except females aged 18 to 21 years. In this subgroup, digestive symptoms ranked first in frequency and injury ranked second. In all other subgroups, musculoskeletal symptoms ranked second after injury. Among adolescent males of all ages, injury was more than twice as common as musculoskeletal symptoms. Among adolescent fe-males, genitourinary symptoms increased in fre-quency with age.

The most common principal reasons for adolescent visits to emergency departments by sex are shown in Tables 7 and 8. Females were most likely to present with abdominal pain or sore throat, whereas males were most likely to present with arm, hand, and finger injuries. Headache ranked third among both females and males and accounted for 3.6% and 3.1% of the visits, respectively.

The leading diagnostic categories for adolescent visits to emergency departments by age group and sex are summarized in Table 9. Injury was the lead-ing diagnostic category in all age groups for both male and female adolescents. The category of respi-ratory diagnoses ranked second in all groups except females aged 18 to 21 years; in this group it ranked third after ill-defined conditions. The category of

TABLE 5. Percentage of Emergency Department Visits by Age and Sex Made Because of Injury*

Age (y) Male Female

,11 24.8 (1.0) 21.0 (1.0)

11–14 42.0 (2.4) 27.2 (2.3)

15–17 37.7 (2.5) 19.6 (2.1)

18–21 36.6 (5.8) 14.1 (1.4)

22–44 27.3 (0.8) 15.0 (0.6)

45–64 19.1 (1.2) 15.6 (1.0)

.65 10.6 (1.0) 13.2 (0.9)

* Standard error is shown in parentheses. TABLE 7. Leading Principal Reasons for Emergency

Depart-ment Visits Made by Males Aged 11 to 21 Years*

Reason RVC Code† Percent

Upper extremity lacerations and cuts 5225.0 5.5 (0.6)

Unspecified hand/finger injury‡ 1960.1 3.2 (0.5)

Headache 1210.0 3.1 (0.5)

Unspecified head, face, neck injury‡ 5505.0 3.0 (0.5)

Sore throat 1455.1 2.7 (0.5)

Abdominal pain 1545.1 2.6 (0.4)

Chest pain 1050.1 2.3 (0.4)

Facial lacerations and cuts 5210.0 2.2 (0.4)

Lower extremity lacerations and cuts 5220.0 1.9 (0.4)

Hand/finger pain 1960.1 1.9 (0.4)

Fever 1010.0 1.9 (0.4)

Back pain 1905.1 1.8 (0.4)

Neck pain 1900.1 1.7 (0.4)

* Number is percentage of all visits made for given reason within the group. Standard error is shown in parentheses.

† Based on Reason for Visit Classification (RVC) Code.15 ‡ No specific type of injury is mentioned.

TABLE 8. Leading Principal Reasons for Emergency Depart-ment Visits Made by Females Aged 11 to 21 Years*

Reason RVC Code† Percent

Abdominal pain 1545.1 8.5 (0.8)

Throat soreness 1455.1 5.2 (0.6)

Headache 1210.0 3.6 (0.5)

Earache 1355.1 2.6 (0.4)

Chest pain 1050.1 2.5 (0.4)

Back pain 1905.1 2.2 (0.4)

Flank pain 1055.2 2.2 (0.4)

Uterine/vaginal bleeding 1755.0 2.0 (0.4)

Upper extremity lacerations 5225.0 2.0 (0.4)

Fever 1010.0 1.9 (0.4)

Vomiting 1530.0 1.6 (0.3)

Unspecified head, face, neck injury‡ 5505.0 1.6 (0.3)

Unspecified ankle injury‡ 5540.0 1.6 (0.3)

* Number is percentage of all visits made for given reason within the group. Standard error is shown in parentheses.

† Based on Reason for Visit Classification (RVC) Code.15 ‡ No specific type of injury is mentioned.

TABLE 6. Leading Reason Categories for Adolescent Emergency Department Visits by Age and Sex*

Category† RVC Code1 11 to 14 y 15 to 17 y 18 to 21 y

Male Female Male Female Male Female

Injury 5001–5899 42.0 (2.4) 27.2 (2.3) 37.7 (2.5) 19.6 (2.0) 36.6 (2.1) 14.1 (1.3)

Musculoskeletal 1900–1999 19.2 (1.9) 17.4 (2.0) 17.4 (2.0) 16.0 (1.9) 17.3 (1.7) 13.2 (1.3)

Respiratory 1400–1499 7.3 (1.2) 7.5 (1.4) 9.3 (1.5) 12.6 (1.7) 8.0 (1.2) 11.2 (1.3)

Digestive 1500–1639 7.2 (1.3) 13.0 (1.8) 5.1 (1.1) 14.7 (1.8) 6.7 (1.1) 18.8 (1.6)

General‡ 1001–1099 6.7 (1.2) 11.0 (1.6) 10.1 (1.6) 10.8 (1.6) 8.4 (1.2) 11.6 (1.3)

Skin, nails, hair 1830–1899 3.6 (0.9) § § § § 1.9 (0.5)

Neurological 1100–1199 3.3 (0.9) 5.3 (1.2) 5.8 (1.1) 4.8 (1.1) 5.4 (1.0) 6.6 (1.0)

Genitourinary 1640–1829 § § § 8.5 (1.4) § 9.8 (1.2)

Eyes and ears 1300–1399 3.1 (0.1) 6.9 (1.3) § § 3.9 (0.9) 4.7 (0.8)

* Number is percentage of all visits made for given reason within the defined age-sex group. Standard error is shown in parentheses. † All categories except injury refer to symptoms pertaining to given system.

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genitourinary diagnosis appeared in the female list at ages 11 to 14 years and increased fourfold in frequency by ages 18 to 21 years. The category of pregnancy-related diagnoses accounted for 80 000 visits (4.0%) of females aged 15 to 17 years, and increased to 215 000 visits (6.3%) by ages 18 to 21 years.

The most common specific diagnoses unrelated to injury rendered for adolescent emergency depart-ment visits by sex are listed in Tables 10 and 11. Among both females and males, acute pharyngitis and ill-defined abdominal symptoms ranked in the top three noninjury-related diagnoses.

DISCUSSION

Adolescence is a unique developmental stage, characterized by dramatic physiological and psycho-logical changes. With these changes come special concerns, needs, and behaviors regarding health care.20,21 Inadequate health insurance, inconvenient

or inappropriate service sites, and concerns about confidentiality are a few of the many barriers that affect adolescent access to health care.21–24These bar-riers, along with the rapid physical and psychologi-cal changes of puberty, contribute to different utili-zation patterns of health care services by adolescents compared with children and adults.20 Furthermore, utilization may change during adolescence as biol-ogy, behavior, and attitudes toward health care ma-ture.

The major health risks for adolescents are behav-ioral and social rather than biomedical.25,26 Injury, homicide, and suicide have long replaced infection, malignancy, and cardiovascular disease as the lead-ing causes of adolescent mortality. National data sources throughout the 1990s have documented un-acceptably high rates of substance use, sexually transmitted disease, and unintended pregnancy. In 1993, unintentional injury and violence accounted for 80% of deaths among adolescents aged 15 to 19

TABLE 11. Leading Diagnoses (Excluding Injuries) Associ-ated with Emergency Department Visits Made by Females Aged 11 to 21 Years*

Diagnosis ICD-9-CM

Codes†

Female Percentage

Abdominal symptoms‡ 789 5.1 (0.6)

Urinary tract disease 599 3.1 (0.5)

Acute pharingitis 462 2.6 (0.4)

Unspecified noninfectious gastroenteritis and colitis

558 2.0 (0.4)

Otitis media 382 2.0 (0.4)

Asthma 493 1.7 (0.4)

Pelvic inflammatory disease 614 1.6 (0.3)

Respiratory symptoms‡ 786 1.6 (0.3)

Incidental pregnancy state V22.2 1.5 (0.3)

Acute upper respiratory infection 465 1.5 (0.3)

* Number is percentage of all visits yielding diagnostic category within age-sex group. Standard error is shown in parentheses. † Based on the International Classification of Diseases, 9th Revi-sion, Clinical Modification (ICD-9-CM).16

‡ Symptoms are ill-defined diagnoses.

TABLE 9. Leading Diagnostic Categories Associated With Adolescent Emergency Department Visits by Age and Sex*

Diagnosis ICD-9-CM

Code†

11 to 14 y 15 to 17 y 18 to 21 y

Male Female Male Female Male Female

Injury‡ 800–959 61.6 (2.4) 45.8 (2.6) 55.4 (2.6) 32.9 (2.5) 55.5 (2.2) 26.3 (1.8)

Respiratory 460–519 8.0 (1.3) 8.4 (1.5) 11.6 (1.7) 12.6 (1.7) 9.4 (1.3) 11.4 (1.3)

Ill-defined 780–799 5.1 (1.1) 9.7 (1.6) 3.3 (0.9) 7.9 (1.4) 9.4 (1.3) 11.6 (1.3)

Infectious 001–139 3.9 (1.0) 5.1 (1.1) 4.9 (1.1) 3.7 (1.0) # 3.8 (0.8)

Digestive 520–579 3.1 (0.9) 4.5 (1.1) 3.2 (0.9) 5.4 (1.2) 3.3 (0.8) 5.6 (0.9)

Neurologic 320–389 3.1 (0.9) 7.1 (1.4) 3.5 (1.0) # 3.3 (0.8) 5.3 (0.9)

V-Codes§ V01–V82 3.1 (0.9) 3.4 (1.0) # 6.8 (1.3) 5.2 (1.0) 7.0 (1.0)

Dermatology 680–709 2.9 (0.8) # # # 2.4 (0.7) 2.7 (0.6)

Musculoskeletal\ 710–739 # 3.4 (1.0) # 3.1 (0.9) 2.8 (0.7) 2.2 (0.6)

Genitourinary 580–629 # 3.1 (0.9) # 11.1 (1.6) # 12.6 (1.3)

Mental disorders 290–319 # # 3.0 (0.9) 3.9 (1.0) 3.0 (0.8) 2.0 (0.6)

Pregnancy complication¶

630–676 # # # 4.0 (1.0) # 6.3 (1.0)

* Number is percentage of all visits yielding diagnostic category within age-group. Standard error is shown in parentheses. † Based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).16

‡ Excludes poisoning.

§ V-Codes refer to diagnoses unrelated to disease or injury (eg, routine examination, prophylactic immunization) or for treatment of pre-existing condition (eg, dialysis, chemotherapy).

\Includes connective tissue diseases.

¶ Includes complications of pregnancy, child birth, and preperium. # Data do not meet release criteria.

TABLE 10. Leading Diagnoses (Excluding Injuries) Associ-ated with Emergency Department Visits Made by Males Aged 11 to 21 Years*

Diagnosis ICD-9-CM

Codes†

Male Percentage

Acute pharingitis 462 2.2 (0.4)

Asthma 493 2.1 (0.4)

Abdominal symptoms‡ 789 2.1 (0.4)

General symptoms‡ 780 1.6 (0.4)

Respiratory symptoms‡ 786 1.4 (0.3)

Acute conjunctivitis 372 1.3 (0.3)

Acute upper respiratory infection 465 1.2 (0.3)

Unspecified noninfectious gastroenteritis and colitis

558 1.1 (0.3)

Acute bronchitis 490 1.0 (0.3)

Acute tonsillitis 463 1.0 (0.3)

* Number is percentage of all visits yielding diagnostic category within age-sex group. Standard error is shown in parentheses. † Based on the International Classification of Diseases, 9th Revi-sion, Clinical Modification (ICD-9-CM).16

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years.25,26 Between 1960 and 1993, the suicide rate among adolescents aged 10 to 19 years increased 200% compared with a 17% increase for the general population.25,27Substance use among high school se-niors has climbed steadily since 1991, after almost 15 years of steady decline.28 More than two-thirds of high school seniors have had sexual intercourse.29 One-quarter of the 12 million cases of sexually trans-mitted disease reported annually to the Centers for Disease Control and Prevention are adolescents. Of the 1 million adolescent pregnancies annually, 85% are unintended.30,31

Despite these alarming public health problems, adolescents are more likely to be uninsured and less likely to utilize office-based health services than any other age group in the United States.20In fact, health insurance status among adolescents deteriorated during the 1980s.2 Adolescents at greatest risk for health problems (impoverished, homeless, runaway, and parenting youth) are the very adolescents most likely to be uninsured and to have poor access to care.2,3

The existing literature on adolescent health and health care utilization is extensive but hampered by several design limitations. Most importantly, adoles-cence typically is not considered separately from childhood or young adulthood. Many national sur-veys group their study participants as children younger than 15 years and young adults 15 to 24 years. Other studies use age 18 years as the cut-point. Still others separate adolescents but vary widely in their age definitions of adolescence. The most useful data sources divide adolescence into early (10 to 14 years) and late (15 to 19 years) cohorts. This age division, however, is not consistent with that utilized by two recent guidelines for adolescent primary care.11,12Both the American Medical Association and the Maternal and Child Health Bureau have devel-oped separate health care recommendations for early (11 to 14 years), middle (15 to 17 years), and late (18 to 21 years) adolescence. As these guidelines increas-ingly become a part of standard care practice, it will be important to utilize the same age definitions in assessing adolescent health status, health outcomes, and service utilization.

In addition to the problem of age definition, the few available national surveys of adolescent health care utilization are out-dated and focus only on of-fice-based visits.6,10 The low utilization documented in these surveys may be associated with high, but undocumented, utilization of emergency and hospi-tal-based services. The few studies on emergency department utilization by adolescents are based on small, locally drawn samples.8,9 Consequently, little is known about adolescent utilization of emergency services nationwide or the trends in utilization that may evolve during adolescence.

Our analysis was designed to explore emergency department utilization during the course of adoles-cence. We utilized the same age groups defined in the recent guidelines for adolescent care.11,12The ra-tionale for this age division stems from the concept that each subgroup has unique developmental tasks that affect health needs and behaviors. These

differ-ences may play an important role in shaping adoles-cent health-care utilization patterns.

The importance of age subgroups becomes imme-diately apparent in our analysis of the number of visits made to emergency departments. At first glance, the NHAMCS data suggest that adolescents utilize emergency departments at a rate that closely matches their proportion in the population. How-ever, subgroup analyses reveal that older adoles-cents, aged 18 to 21 years, overutilize emergency department services whereas young adolescents, aged 11 to 14 years, underutilize emergency depart-ment services. This same pattern was described by Lehmann8in a 1994 study of a rural, general hospital emergency department. Possible explanations for these findings include better health, less risk behav-ior, and better utilization of primary care resources among younger than older adolescents.25,26The find-ing that adolescents do not underutilize emergency departments but do underutilize office-based ser-vices suggests that they may delay care until a crisis arises or a health problem escalates. Another possi-bility is that adolescents who are concerned about confidentiality, consent, or parental notification may prefer the relative anonymity of the emergency de-partment setting to the ongoing patient-provider re-lationship of the office.21

Black adolescents accounted for a higher propor-tion of emergency department visits relative to their population proportion, whereas white adolescents accounted for a lower proportion of visits relative to population. Lieu et al,32 in an analysis of the 1988 National Health Interview Survey, reported that black adolescents, compared with white adolescents, were more likely to underutilize primary care ser-vices, yet to report poor health status. Furthermore, several investigators have noted that some risk be-haviors (eg, violence, early sexual activity) with ad-verse health consequences (eg, homicide, pregnancy, sexually transmitted disease) are more common among black than white adolescents.25,26 The lower access to and utilization of primary care services by black compared with white adolescents, may par-tially explain our finding of higher utilization of emergency services by black compared with white adolescents.

One of the most important reasons for underutili-zation of office-based services and overutiliunderutili-zation of emergency services by adolescents may be absent or inadequate health insurance. Access to office-based, nonemergency services depends largely on the abil-ity to pay for these services.33Adolescent utilization of ambulatory services has been shown to be strongly associated with health insurance3,4,32–34. De-spite these known associations, lack of insurance is more prevalent among adolescents and young adults than any other age group in the population.20 Unin-sured adolescents are less likely than inUnin-sured adoles-cents to have seen a physician within 2 years2yet are more likely to have significant health problems.32,33

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higher among adolescents using emergency depart-ments than in previous surveys of adolescents in the general population. In our analysis, 26% of adoles-cents aged 11 to 21 years visiting emergency depart-ments were uninsured. In the 1989 National Health Interview Survey, 15% of adolescents aged 10 to 18 years in the general population were uninsured. The rate of public insurance was higher among adoles-cents visiting emergency departments than in the general adolescent population (27% vs 10%), whereas the rate of private insurance was lower (46% vs 73%). The majority (53%) of adolescents utilizing emergency departments therefore had no insurance or public insurance.

There are, however, marked differences in insur-ance status between adolescent males and females of different ages. Between early and late adolescence, the prevalence of no insurance increased far more for males than for females (148% vs 31%). Although the rate of private insurance dropped in both groups, the rate of public insurance increased for females yet decreased for males. The most likely explanation for this finding is the large proportion of visits made to emergency departments by older adolescent females who are pregnant and eligible for public insurance.

The high uninsurance rate for older adolescent males is particularly worrisome given their high rates of preventable risk behaviors.25,26 The rates of unintentional injury, violence, and homicide are higher for males aged 15 to 24 years than for any other age/sex group in the United States.25,26 Conse-quently, adolescent and young adult males are at high risk for health crises and unpaid medical ex-penses. In our analysis, more than twice as many emergency department visits were injury-related for adolescent males than females and the difference widened as adolescence progressed. Males are more likely than females throughout adolescence to seek emergency department care for urgent problems. These findings support data accrued from other types of analyses (eg, mortality and hospital-dis-charge data),25,26,35,36 and highlight the severity and dominant role of risk-taking behavior and injury in the overall health status of adolescents.

Injury and musculoskeletal symptoms were the leading reasons for emergency department visits made by adolescents in all age/sex groups except females aged 18 to 21 years. This subgroup was more likely to present with digestive symptoms than either injury or musculoskeletal symptoms. Interestingly, nondigestive diagnoses were made in more than 65% of females aged 18 to 21 years presenting with diges-tive symptoms. The most common principal diag-noses in this subgroup were ill-defined abdominal symptoms, pregnancy-related problems, urinary tract infection, and pelvic inflammatory disease.

Common medical diagnoses associated with both males and females visits to emergency departments included acute pharyngitis, ill-defined abdominal and respiratory symptoms, asthma, and upper respi-ratory infection. The low rate of hospitalization among patients with these diagnoses and the simi-larity of this list with that compiled in studies of adolescent office visits6,10 suggest that many

adoles-cents do indeed use emergency departments for pri-mary health care.

There are important limitations to our study. First, it is primarily descriptive, intended to provide the reader with a broad overview of emergency depart-ment use by adolescents. The data do not permit detailed explanation of the determinants of use, trends throughout time, or cause/effect relationships that might exist between insurance status and use. Second, the study utilizes cross-sectional, facility-based data with emergency room encounters as the units of observation. Comparison with population-based studies is difficult given differences in the format of data collection, time periods, and age groupings. This limitation highlights the need for a uniform classification of adolescent age subgroups that is consistent with current guidelines for adoles-cent health care. Third, the nature of this database, designed to provide estimates through sampling weights, limits the investigation of uncommon visit characteristics or the combination of visit character-istics. The integrity of the data is protected through strict release criteria established by the National Cen-ter for Health Statistics.14

Our analysis raises several questions for future study. First, is the overutilization of emergency de-partments by adolescents largely a reflection of in-adequate health insurance or might older adoles-cents actually prefer emergency departments to office-based settings? This issue could be addressed through focused exit surveys or the addition of more specific questions on national surveys. Second, do insured and uninsured adolescents differ in their reasons for seeking care from emergency depart-ments or in their resulting diagnoses? Third, are adolescents more likely than children or adults to utilize emergency departments repeatedly? If so, the same adolescents may account for a large proportion of the visits. Fourth, what are the characteristics of adolescent visits to nonemergency, primary care set-tings and how do they compare to the current find-ings?

CONCLUSIONS

Utilization of emergency departments increases with adolescent age. Younger adolescents underuti-lize emergency departments, whereas older adoles-cents overutilize emergency departments. As utiliza-tion increases, so too does the absence of health insurance. High utilization and lack of insurance are particularly notable for older adolescent males, sug-gesting low access to and use of alternative primary care services.

The policy implications of these findings are clear. Adolescents must have access to health insurance and primary care services. Only then will adoles-cents and health care providers shift from a model of crisis intervention to one of anticipatory guidance, screening, and primary prevention.

ACKNOWLEDGMENTS

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1992;90:589 –596

3. Newacheck PW, McManus MA, Gephart J. Health insurance status of young adults in the United States.Pediatrics.1989;84:699 –708 4. McManus MA, Greaney AM, Newacheck PW. Health insurance status

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6. Cypress BK. Health care of adolescents by office-based physicians: National Ambulatory Medical Care Survey, 1980 – 81. Advance Data From Vital and Health Statistics. No. 99. Hyattsville, MD: National Center for Health Statistics; DHHS Publication No. (PHS) 84 –1250; 1984 7. Wood DL, Hayward RA, Corey CR, et al. Access to medical care for

children and adolescents in the United States. Pediatrics. 1990;86: 666 – 673

8. Lehmann CU, Barr J, Kelly PJ. Emergency department utilization by adolescents.J Adolesc Health.1994;15:485– 490

9. Melzer-Lange M, Lye PS. Adolescent health care in a pediatric emer-gency department.Ann Emerg Med.1996;27:633– 637

10. Nelson C. Office visits by adolescents. Advance Data From Vital and Health Statistics. No. 196. Hyattsville, MD: National Center for Health Statistics; 1991

11. Department of Adolescent Health.Guidelines for Adolescent Preventive Services. Chicago, IL: American Medical Association; 1992

12. Green M. Bright Futures. Guidelines for Health Supervision of Infants, Children and Adolescents. Arlington, VA: National Center for Education in Maternal and Child Health; 1994

13. Stussman BJ. National Hospital Ambulatory Medical Survey: 1994 Emergency Department.Advance Data From Vital and Health Statistics. No. 275. Hyattsville, MD: National Center for Health Statistics, DHHS Publication No.(PHS) 96 –1250; 1996

14. McCraig LF, McLemore T. Plan and operation of the National Hospital Medical Care Survey. National Center for Health Statistics.Vital Health Stat. 1994;1(34)

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24. Klein JD, Slap GB, Elster A, Schonberg SK. Access to health care for adolescents: a position paper for the Society for Adolescent Medicine.J Adolesc Health.1992;13:162–170

25. Ozer EM, Brindis CD, Millstein SG, Knopf DK, Irwin CE Jr.America’s Adolescents: Are They Healthy?San Francisco, CA: University of Califor-nia, San Francisco, National Adolescent Health Information Center; 1997

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death, and related risk behaviors among US adolescents.Adolescent Health: State of the Nation Monograph Series #1. Atlanta, GA: Centers for Disease Control and Prevention; 1993. CDC Publication No. 099 – 4112 36. McManus MA, McCarthy E, Kozak LJ, Newacheck PD. Hospitals use by

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DOI: 10.1542/peds.101.6.987

1998;101;987

Pediatrics

Amitai Ziv, Jack R. Boulet and Gail B. Slap

Emergency Department Utilization by Adolescents in the United States

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DOI: 10.1542/peds.101.6.987

1998;101;987

Pediatrics

Amitai Ziv, Jack R. Boulet and Gail B. Slap

Emergency Department Utilization by Adolescents in the United States

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Figure

TABLE 1.Emergency Department Visits, and Percent of Pop-ulation by Age Group

TABLE 1.Emergency

Department Visits, and Percent of Pop-ulation by Age Group p.2
TABLE 2.Percentage of Emergency Department Visits and Population by Age Group, Sex, and Race*

TABLE 2.Percentage

of Emergency Department Visits and Population by Age Group, Sex, and Race* p.3
TABLE 3.Emergency Department Visits by Health Insurance Status, Age, and Sex*

TABLE 3.Emergency

Department Visits by Health Insurance Status, Age, and Sex* p.3
TABLE 4.Percentage of Emergency Department Visits byAge and Sex That Were Urgent and/or Resulted in Hospitaliza-tion*

TABLE 4.Percentage

of Emergency Department Visits byAge and Sex That Were Urgent and/or Resulted in Hospitaliza-tion* p.3
TABLE 7.Leading Principal Reasons for Emergency Depart-ment Visits Made by Males Aged 11 to 21 Years*

TABLE 7.Leading

Principal Reasons for Emergency Depart-ment Visits Made by Males Aged 11 to 21 Years* p.4
TABLE 8.Leading Principal Reasons for Emergency Depart-ment Visits Made by Females Aged 11 to 21 Years*

TABLE 8.Leading

Principal Reasons for Emergency Depart-ment Visits Made by Females Aged 11 to 21 Years* p.4
TABLE 6.Leading Reason Categories for Adolescent Emergency Department Visits by Age and Sex*

TABLE 6.Leading

Reason Categories for Adolescent Emergency Department Visits by Age and Sex* p.4
TABLE 5.Percentage of Emergency Department Visits byAge and Sex Made Because of Injury*

TABLE 5.Percentage

of Emergency Department Visits byAge and Sex Made Because of Injury* p.4
TABLE 9.Leading Diagnostic Categories Associated With Adolescent Emergency Department Visits by Age and Sex*

TABLE 9.Leading

Diagnostic Categories Associated With Adolescent Emergency Department Visits by Age and Sex* p.5
TABLE 11.Leading Diagnoses (Excluding Injuries) Associ-ated with Emergency Department Visits Made by Females Aged11 to 21 Years*

TABLE 11.Leading

Diagnoses (Excluding Injuries) Associ-ated with Emergency Department Visits Made by Females Aged11 to 21 Years* p.5
TABLE 10.Leading Diagnoses (Excluding Injuries) Associ-ated with Emergency Department Visits Made by Males Aged 11to 21 Years*

TABLE 10.Leading

Diagnoses (Excluding Injuries) Associ-ated with Emergency Department Visits Made by Males Aged 11to 21 Years* p.5