Emergency Department and Urgent Care for Children Excluded From Child Care

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Excluded From Child Care

WHAT’S KNOWN ON THIS SUBJECT: Previous studies have revealed that children in child care are frequently ill with mild illness and are unnecessarily excluded from child care at high rates.

WHAT THIS STUDY ADDS: Parent race/ethnicity, single parents, and work-related concerns are associated with increased emergent/urgent care use for a sick child excluded from child care, even for mild illnesses.

abstract

BACKGROUND:Children in child care are frequently unnecessarily ex-cluded for illness. We investigated parental use of urgent medical evaluation for sick children unable to attend child care.

METHODS:In May 2012, authors conducted a nationally representative survey of parents, who completed online questions regarding child ill-ness causing absence from child care and their medical care-seeking behavior. Main outcome was parents’use of emergency department or urgent care (ED/UC).

RESULTS:Overall survey participation rate was 62%. Of participating parent cohort with children 0 to 5 years old, 57% (n= 357) required child care, of which 84% (n= 303) required out-of-home child care. Over 88% of parents sought acute medical care for their sick chil-dren unable to attend child care. Approximately one-third of par-ents needed a doctor’s note for employers and/or child care. Parents sought medical evaluation (.1 option possible) from primary care (81%), UC (26%), or ED (25%). ED/UC use was most common for rash (21%) and fever (15%). Logistic regression indicated ED/UC use was signiﬁcantly higher among single/divorced parents (odds ratio [OR] = 4.3; 95% conﬁdence interval [CI]: 2.5–13.5); African American parents (OR = 4.2; 95% CI: 1.2–14.6); parents needing a doctor’s note (OR = 4.2; 95% CI: 1.5–11.7); and those with job concerns (OR = 3.4; 95% CI: 1.2–9.7).

CONCLUSIONS: A substantial proportion of parents whose sick chil-dren cannot attend child care seek care in ED/UC. Training child care professionals regarding appropriate illness exclusions may decrease ED/UC visits by lowering child care exclusions. Pediatrics

2014;134:e120–e127

AUTHORS:Andrew N. Hashikawa, MD, MS,a_{David C.}

Brousseau, MD, MS,b_{Dianne C. Singer, MPH,}c_Achamyeleh

Gebremariam, MS,c_{and Matthew M. Davis, MD, MAPP}c,d a_{Department of Emergency Medicine,}c_{Child Health Evaluation} and Research Unit, University of Michigan Medical School, Ann Arbor, Michigan;b_{Section of Pediatric Emergency Medicine,} Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; andd_{Institute of Healthcare Policy and} Innovation and Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, Michigan

KEY WORDS

child care, illness, urgent care, emergency care, policy, survey, and parents

ABBREVIATIONS

AAP—American Academy of Pediatrics ACA—Affordable Care Act

aOR—adjusted odds ratio CI—conﬁdence interval ED—emergency department GfK—GfK Custom Research, LLC NPCH—National Poll on Children’s Health OR—odds ratio

UC—urgent care

Dr Hashikawa conceptualized and designed the study, helped with data acquisition, and drafted the initial manuscript; Dr Brousseau helped conceptualize and design the study, contributed substantially to data interpretation, and critically reviewed and revised the manuscript; Ms Singer made substantial contributions to study design, study analysis and data interpretation, and critically reviewed the manuscript; Mr Gebremariam carried out data analysis and interpretation and critically reviewed the manuscript; Dr Davis made substantial contributions to study design and development of data collection instruments and critically reviewed and revised the manuscript; and all authors approved theﬁnal manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-3226

doi:10.1542/peds.2013-3226

Accepted for publication Mar 25, 2014

Address correspondence to Andrew N. Hashikawa, MD, MS, Department of Emergency Medicine, Children’s Emergency Services, 2800 Plymouth Rd, Suite G080, NCRC Building 10, Ann Arbor, MI 48109-2800. E-mail: drewhash@umich.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE:The authors have indicated they have noﬁnancial relationships relevant to this article to disclose. FUNDING:No external funding.

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More than 80% of the children in the United States will require nonparental child care by 6 years of age because of working parents, welfare reform, and economic necessity.1–3_{Children in child} care center settings have more upper respiratory infections, diarrheal illness, ear infections, and myringotomy tube placement than children who stay at home exclusively.4–7

Previous research demonstrates that ill children are routinely excluded from child care unnecessarily given that most child care-related illnesses are minor in severity.8_–11 _Unnecessary exclusions place a substantial burden on working families, businesses, and health care resources.1,9,12–18 Nation-ally, an estimated 44 million workers lack any paid sick leave beneﬁts to care for sick children, disproportion-ately affecting poor and minority families.19

The American Academy of Pediatrics (AAP), in its publicationCaring for Our Children: National Health and Safety Performance Standards for Out-of-Home Child Care and Early Education Programs,20 _{outlined clear child care} illness exclusion guidelines, particularly if the child cannot participate comfort-ably in activities or needs more attention that staff can provide safely. Several studies demonstrate that child care provider adherence to the guidelines is low, however, and training is unavailable in most states.8,9,21,22

Consequently, child care providers un-aware of AAP national child care rec-ommendations may increase parents’ perceived need for urgent medical evaluations for nonurgent conditions to avoid loss of wages or missed time from work.23–26 _{An estimated 50% to} 80% of the 25 million pediatric visits to the emergency department are for nonurgent conditions.27–30 _High emer-gency department (ED) utilization for nonurgent conditions leads to increased cost, prolonged wait times, patient

dis-satisfaction, and adverse events.28,31 Studies suggest that most families seeking nonurgent pediatric ED visits report having a regular primary care physician.27,32 _{Multiple factors} asso-ciated with pediatric nonurgent ED utilization have been identiﬁed, in-cluding single parent status, Medicaid insurance, lack of convenient/weekend hours, parent ED utilization, and quality of relationship with primary care pro-vider.27,28,33,33_{Many of these factors are} prominent characteristics of parents who need child care services. No studies of pediatric ED or acute care use, however, have assessed the im-pact that child care illness might have on parents’need for urgent medical evaluations.

The C.S. Mott Children’s Hospital Na-tional Poll on Children’s Health (NPCH) survey was used to investigate the pre-valence and characteristics of parents who use the ED or urgent care (UC) for sick children unable to attend child care.

METHODS

Study Design and Sample

The NPCH, located within the Child Health Evaluation and Research Unit of the Division of General Pediatrics at the University of Michigan, measures per-ceptions concerning major health care issues and trends for US children. The NPCH is conducted in partnership with the GfK Custom Research, LLC (GfK) Group’s Web-enabled KnowledgePanel, a probability-based panel designed to be representative of the US population. The KnowledgePanel has served as the sampling frame for several other peer-reviewed studies on health topics re-lated to children.34_–37

The NPCH sample includes oversampling of parents and members of racial and ethnic minorities to ensure adequate representation of those groups. Panel participants were originally chosen through random selection of telephone

numbers and residential addresses and were invited by GfK to participate by telephone or mail. If individuals agree to participate but do not already have In-ternet access, GfK provides them a lap-top and Internet service connection at no cost. Panelists receive unique log-in information for accessing surveys online, and then are sent emails each month inviting them to participate in research on a wide array of topics. After joining the panel, participants provide individual and household demographic data, used for sampling purposes.

The survey for the current study was piloted in April 2012 by using a separate convenience sample of 105 Knowledge-Panel participants. The process for the pretest sample is very similar to the process for the main survey, with iden-tical sample definitions in both samples. When the survey items were judged by the investigators to be functioning as intended, thefinal survey wasfielded in May 2012. Eligible participants in the survey were adults 18 years or older. This study is based on responses of parents with children 0 to 5 years old in child care. The study was approved by the University of Michigan Medical School Institutional Review Board.

Survey Items

The focus of this study was on parental responses to 5 questions related to child care and illness, within a larger survey of 52 questions on topics in-cluding bullying, hearing loss, top child health concerns in respondents’ com-munities, and whole genome sequenc-ing. The survey questions related to child care and illness developed by the study team are presented in Fig 1: for purposes of analysis,“child care”also included “daycare” and “preschool” settings. Only children who required care outside their homes were included. For parents with.1 child, each parent was asked to select the youngest child as the index case for purposes of this study.

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Parents completed survey questions regarding illnesses that caused absence from child care and medical care-seeking behavior when their children could not attend child care. Five hypo-thetical vignettes about a child with ill-ness symptoms (cold symptoms without fever, conjunctivitis, gastroenteritis, mild fever, and ringworm), adapted from Copeland et al8 _{and previously} used by the authors,9,21_{were presented} to each respondent (Fig 1). For each of the illness vignettes, parents chose whether the child would be a) sent to child care despite symptoms; b) ex-cluded by child care because of illness; or c) kept at home even if the child was allowed at child care. Parents were also asked if they would take their children for medical care if their children de-veloped symptoms the evening before an important parent meeting. The me-dian time to complete the survey was 10 minutes.

Survey Analysis

Deidentiﬁed data were presented from the survey partner to the authors, with sampling weights on the basis of the US Census to yield nationally representa-tive estimates. All result data are pre-sented weighted for the US population.

Bivariate analyses (x2 tests) were conducted for the relationship be-tween parent-reported ED/UC use and several parent (gender, race, parent education, household income, house ownership status, housing type) and child (insurance status, allergy status, asthma status, seizure, lung disease from prematurity, obesity) character-istics. The primary outcome was parent’s use of either the ED or UC for their child. Parents’choices of site of urgent medical care (ED, UC, or pri-mary care provider) were initially an-alyzed separately, but UC and ED were then combined forﬁnal analysis, given the sample size and distribution of answers.

The authors then applied logistic re-gression models to examine the asso-ciations between parent-reported ED/UC use and child variables. All variables achieving aP,.05 level of signiﬁcance in bivariate analyses were retained in ourﬁnal multivariate model. Descriptive statistics were used to summarize responses to vignettes.

RESULTS

Study Participants

Overall survey participation rate was 62%. Among the participating cohort of parents with children 0 to 5 years old (n= 630), 57% of parents (n= 357) required child care for at least 1 child, of which 84% (n= 303) of parents had a child requiring child care outside the home. Parent and child demographics are presented in Table 1.

Overall, 38% of parents required a doctor’s note either for their own work (20%), and/or so their children could return to child care (30%). One-third of parents (33%) were concerned about loss of job or pay when taking time off of work to care for their sick children when those children were unable to attend child care.

Most parents (88%) took their children to a medical provider when their sick children were unable to attend child care. Although 80% of parents reported seeking medical care for their sick child in the past year at a primary care physician’s ofﬁce, substantial proportions of parents also reported choosing UC (26%) or ED (25%) settings.

Factors Associated With ED/UC Utilizations: Bivariate Analysis

In bivariate analyses, ED/UC use was signiﬁcantly higher among parents needing a doctor’s note (versus those who did not), parents with work con-cerns (versus those without), African American parents (versus all others), single/divorced parents (versus mar-ried parents); and parents with

an-nual household income,$60 000 (vs

$$60 000). Parent education level, child insurance status, and other child variables were not statistically signif-icantly associated with ED/UC use in our analysis.

Parents’need for a doctor’s note, par-ent race/ethnicity, marital status, and parent work concerns remained sta-tistically signiﬁcant in multivariate analyses. ED/UC use was higher among parents needing a doctor’s note (ad-justed odds ratio [aOR] = 4.2; 95%

con-ﬁdence interval [CI]: 1.5–11.7). African American parents were more likely than

TABLE 1 Parent and Child Characteristics

Parent and Child Characteristics,N= 303 %

Parent gender

Women 53

Men 47

Parent race/ethnicity

Non-Hispanic white 59

Non-Hispanic black 16

Other non-Hispanic 6

Hispanic 19

Parent marital status

Married 71

Living with partner 13

Never married 10

Divorced 4

Separated 2

Annual household income

,$30K 23

$30K to $60K 28

.$60K to#$100K 27

.$100K 22

Parent education level

Less than high school 11

High school 21

Some college 33

Bachelor’s degree or higher 35 Child age

0–11 mo 7

1 y 7

2 y 15

3 y 18

4 y 22

5 y 31

Time in child care

.30 h per week 31

10–30 h per week 40

,10 h per week 29

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Single or divorced parents (aOR = 4.3; 95% CI: 1.4–13.5), and parents with job concerns (loss of pay or job when taking time off work to care for a sick child unable to attend child care; aOR = 3.4; 95% CI: 1.2–9.7) were also more likely to use the ED/UC.

Vignettes and Medical Care-Seeking Behavior

Collectively across all vignettes,.85% of parents would seek acute medical care for their children for any symptoms presented. Parent responses to illness vignettes are presented in Fig 2.

Parent preference for the type of acute medical care (primary care provider versus ED/UC versus no visit) also varied depending on illness symptom in each vignette (Fig 3).

DISCUSSION

Our survey is theﬁrst study to demon-strate that a high proportion of parents report seeking medical evaluation in acute care settings when their children’s illnesses prevent attendance at child care. The potential impact of this type of health care-seeking behavior on health care resources may be substantial given the sheer number of children currently using child care services nationally. Reasons for seeking acute medical care for a child excluded from child care may be multifactorial, with ED/UC use higher among single-parent households, African American parents, parents concerned about job threats to their job or job-related in-come, and parents in need of a doctor’s note.

Our results concur with previous studies that revealed factors associated with nonurgent pediatric emergency visits include single-parent status and the need for convenient before- and after-work hours.27,33 _{Our additional} ﬁ nd-ings that parents at higher risk for using

ED/UC settings for child care illnesses were African American parents and single parents are also consistent with previous studies.23,25 _{Our study did not}

ﬁnd that Hispanic families were at higher risk for ED/UC use, consistent with studies revealing that Hispanic fami-lies are more dependent on child care provided by extended families.38,39

Parents without sick leave beneﬁts face a considerable dilemma as they risk either loss of wages or loss of a job to stay home with a sick child excluded from child care. Parents may view the

situation as a socioeconomic emer-gency, choosing the inconvenience of an urgent medical evaluation over the in-ability to return to work in a timely manner. This choice may partially ex-plain why almost 9 of 10 parents in our study chose to seek medical evaluation when their sick child could not attend child care. Lack of health insurance was not associated with increased ED/UC use because the majority of children in our survey, similar to 2011 national statistics, had health insurance cover-age.40

FIGURE 2

Will parents send a child with symptoms to child care?

FIGURE 3

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Child care illness policies that differ from AAP child care guidelines may im-pact parent medical care-seeking be-havior. The need for a doctor’s note, as reported by almost one-third of parents in our survey, was associated with in-creased ED/UC use for sick children ex-cluded from child care. Many child care settings, in contrast to AAP guidelines, require health care visits before a child can return to child care.21_{National AAP} child care guidelines no longer require a mandatory health visit for many symptoms of illness and children can usually return to child care as long as general exclusion criteria are resolved, the child can participate in usual activ-ities, and child care providers can pro-vide and maintain safe stafﬁng ratios.19,41 A previous study revealed that the ma-jority of parents of children excluded from child care reported they would not have scheduled the medical visit if it were not required by child care poli-cies.42 _{Our study revealed that with} al-most one-third of parents (for fever, pink-eye, rash, and gastroenteritis vignettes) reporting their children would not be allowed in child care, a substantial proportion of parents may be scheduling medical visits on the basis of unnecessary child care illness exclusion policies. Interventions target-ing child care providers to use AAP guidelines to make appropriate exclu-sion and return-to-care deciexclu-sions may decrease parents’need to seek urgent medical evaluation for nonurgent child care illnesses.

All the illness symptoms in the vignettes, per AAP child care guidelines, would not have required immediate exclusion from child care settings. In our study, few parents would send their child with mild symptoms to child care for ringworm, gastroenteritis, or fever. Most parents reported wanting to seek acute medical care for at least 1 of the illnesses in the vignettes. Moreover, parents’decisions to seek urgent medical evaluation varied

by vignette, suggesting parents are more concerned about certain symp-toms (eg, fever, rash) compared with others. Theseﬁndings are consistent with a previous survey of child care center directors, which reported that children with these same symptoms (rash or fever) would be more likely than children with other symptoms to be excluded from child care centers.9

Consistent with previous studies, parents in our national survey reported self-excluding their children from child care, suggesting a lack of knowledge re-garding AAP national child care guide-lines by parents.1,8_{We were surprised} by the proportion of parents who reported they would seek medical care for mild upper respiratory symptoms, with almost one-ﬁfth of parents report-ing they would seek primary care pro-vider evaluation for their child. Given the large number of children in child care settings, parents with sick children unable to attend child care seeking acute medical evaluation may pro-foundly impact available primary care resources.

Our study also indicates that “fever phobia,” described for many years in the literature, continues to exist among parents.43_{Fever education and} antici-patory guidance may beneﬁt parents.44 New parents with young children in child care should be given regular antic-ipatory guidance regarding the expected increase in frequency of infections and the management of common child care related illnesses. Targeted parent educa-tional interventions in child care could help decrease the demand for antibiotics for viral or respiratory conditions.

It is unclear how implementation of the Affordable Care Act (ACA) may affect health care-seeking behavior of parents for children in child care. In this study and others, most families have primary care providers for their child, and expansion of children’s coverage is not a major focus of the ACA. The ACA’s emphasis on

providing care in patient-centered med-ical homes may encourage providers to expand service hours, which can help decrease ED/UC visits for primary care-appropriate conditions.

The child care industry and child care providers face numerous challenges with respect to managing illness in child care settings. Many child care settings are faced with high-turnoverof staff, poor pay, and lack of available health-related training; children with mild illness may place a signiﬁcant strain on child care provider ratios. Additionally, child care providers may face considerable oppo-sition from some parents who feel any illness should be excluded from child care. To help child care providers es-tablish policies for safe and appropriate management of mildly ill children, the AAP has established national recom-mendations that include guidelines that allow for exclusion if staff to child ratio is not adequate or the child cannot par-ticipate comfortably in activities. The AAP has created a new free online learning course via PediaLink available through the AAP’s Healthy Child Care America Web site (http://www.healthychildcare. org) for child care providers to learn how to prevent and manage infectious diseases in child care settings on the basis of AAP national child care guide-lines. Additionally, the AAP Web site offers free, in-training materials that health care trainers can use to teach groups of child care professionals and parents about AAP national child care illness guidelines.45 _{Widespread dissemination} of AAP child care guidelines at the state and national level along with active child care provider training has the potential to decrease parental work absenteeism and health resource utilization.

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spectives of parents with children in child care may have influenced thefindings.34–37 Another limitation in our study design is the use of vignettes to assess deci-sions about child care attendance and care-seeking behavior. It is possible that parents’responses may not reflect actual medical care-seeking behavior. Never-theless, the vignettes provided a stan-dardized approach to assess parents’ care-seeking behavior tendencies, in a manner aligned with AAP guidelines.

Another potential limitation is that the language and structure of the survey items

designed the survey at a Flesch-Kincaid reading level of 3.1 (third grade); addi-tionally, the vignette items have been previously and successfully used in a survey for parents.8 _{Finally, the}ﬁ_fth vi-gnette presented a situation that may potentially represent a bias toward par-ents in professional job settings. The scenario, however, was intentionally non-speciﬁc (parent faced with an important meeting the next day) so that the scenario could still occur for parents employed in minimum wage or job-training settings and not just in professional settings.

A substantial proportion of parents seek care in ED/UC settings for chil-dren excluded from child care for nonurgent conditions. Socioeconomic and parent concerns about loss of pay or job may be signiﬁcant contributors to urgent medical care-seeking be-havior among parents with sick chil-dren unable to attend child care. Adoption of national AAP child care guidelines by states and the training of child care providers and parents may reduce the unnecessary exclusion of ill children and the unnecessary utiliza-tion of ED/UC resources.

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DOI: 10.1542/peds.2013-3226 originally published online June 23, 2014;

2014;134;e120

Pediatrics

Gebremariam and Matthew M. Davis

Andrew N. Hashikawa, David C. Brousseau, Dianne C. Singer, Achamyeleh

Services

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Emergency Department and Urgent Care for Children Excluded From Child Care

Excluded From Child Care

abstract