Michelle L. Macy|Tracie L. Smith|Jenifer Cartland|Emily Golbeck|Matthew M. Davis
Parent?reported hesitancy to seek emergency care for children at the crest of the first wave of COVID?19 in Chicago
Lurie Children's Hospital|Northwestern University|Lurie Children's Hospital|Lurie Children's Hospital|Lurie Children's Hospital|Lurie Children's Hospital|Northwestern University
2009 h1n1 pandemic seasonal influenza outbreaks times overwhelmed capacity childrens hospitals1 covid19 pandemic different relatively children become severely ill infected sarscov22 4 weeks march april 2020 centers disease control prevention found 42 reduction emergency department ed visits nationally compared prior year noted steepest decrease visits among children 15 years3 large urban us childrens hospital reported decline ed visits first 16 weeks 2020 visits higher acuity similar chief complaints compared 2017 20194 authors also observed smaller proportions visits made black publicly insured children little known factors associated caregiver hesitancy seek ed care children pandemic chicago significantly impacted covid19 june 2020 march governor illinois issued stayathome executive order limiting health care seeking emergencies covid19 care closing schools inperson instruction restricting daycare groups 10 fewer children essential workers stayathome order associated substantial reductions health care utilization children metropolitan chicago northern illinois wellchild examinations recovered prepandemic levels june visit types remained suppressed summer 20205 first week may 2020 conducted webbased survey characterize hesitancy seek emergency care children sampled caregivers patients 18 years old ann robert h lurie childrens hospital chicago independent quaternary childrens health system used electronic medical record emr identify children 1 appointment canceled rescheduled due covid19 n 21737 2 seen least two occasions year prior chronic condition asthma prematurity placed influenza vaccine registry n 7966 3 seen ed march 16 april 22 2020 n 2387 survey developed study team fielded english spanish survey questions response options refined based feedback pilot testing experts health services research community engagement study considered exempt human subjects research lurie childrens institutional review board survey links distributed via short messaging service sms message email may 6 2020 using qualtrics survey platform qualtrics reminders sent nonrespondents may 10 2020 day first phase reopening illinois reopening allowed elective medical procedures essential gatherings 10 fewer people respondents offered 5 egift card appreciation time sought 4000 respondents based available institutional resources participant incentives outcome interest response following question assume healthcare facility following current guidelines reduce spread covid19 virus likely would bring child er visit person today needed response options included likely somewhat likely unlikely caregivers considered hesitant seek emergency care response unlikely predictor variables included survey responses data available emr variables obtained via survey included childs raceethnicity caregiver age caregiver language preference childs current health insurance coverage childs health care utilization stayathome order preference inperson telemedicine visit two hypothetical acute conditions sore throat head injury covidpositive individual household agreement stayathome orders compliance stayathome orders emrderived variables included child age sex home address file childs home zip code used determine rate covid cases area dichotomized less equal greater 75th percentile metropolitan chicago census tract childs home address used assign child opportunity index 20 coi score6 chicago metropolitan area census tract collapsed three categories analysis low low moderate high high coi 20 composite measure 29 census tractlevel indicators across three domains education health environment social economic opportunity indicators weighted based impact child health development economic outcomes utilized chisquare statistics calculated proportions 95 confidence intervals cis test associations hesitancy seek emergency care predictor variables stratified coi identified 33513 children emr met study recruitment criteria 31568 94 phone numbers successfully received sms message survey link surveys started 4282 response rate 14 completed 4147 completion rate 97 caregivers distribution respondents reflected distribution clinical groups selected study recruitment child age categories slightly higher responses englishspeaking caregivers white nonlatinx privately insured children per emr spanish language surveys utilized 6 respondents responses collected sms message links 95 n 3705 caregivers whose child appointment canceledrescheduled 70 n 3013 responses received 949 caregivers children influenza vaccine registry 320 visited lurie childrens ed march april excluded 21 respondents answer hesitancy question 230 children without address information 3896 responses analyzed caregiverreported child raceethnicity 48 white nonlatinx 32 latinx race 9 blackafrican american nonlatinx 7 multiple races race 4 asian nonlatinx children 46 female 24 younger 36 months 21 3 5 years 29 6 11 years 26 12 18 years caregiverreported payer 60 private 39 public 1 otheruninsuredno response overall 23 n 879 caregivers hesitant seek emergency care hesitancy differed across coi levels 27 1305 caregivers lowlow coi areas hesitant compared 23 740 caregivers moderate coi areas 19 1851 caregivers highvery high coi areas p 0001 table 1 includes results variables associated hesitancy bivariate analyses p 005 blackafrican american latinx asian raceethnicity child age older 3 years caregiver age 18 30 years language preference english public payer high covidpositivityrate zip code canceledrescheduled appointment associated hesitancy receipt lurie childrens ed care preference inperson visit child sore throat head injury associated less hesitancy proportions caregivers hesitant seek ed care across study variables stratified coi also presented table 1 first wave covid19 metropolitan chicago found nearly one four caregivers hesitant seek ed care child hypothetical emergency condition prior declines acute health care utilization associated covid19 pandemic35 higher ed utilization observed among children african americanblack latinx publicly insured7 researchers focused attention lowacuity ed visits children7 8 observed greater hesitancy within demographic groups previously relied ed pediatric care among caregivers areas lower coi higher community rates covid19 infection potential explanations findings include lower health literacy emergency care seeking higher perceived risks contracting covid19 traveling community health care settings greater hesitancy seek ed care among caregivers preferred telemedicine visits evaluation childs sore throat head injury may signal ed careseeking behaviors influenced expanded telemedicine services hesitancy seek ed care may negative consequences literature describes covid19related delays pediatric care seeking resulted severe diabetic ketoacidosis complicated bacterial infections missed opportunities earlier cancer diagnoses9 10 findings subject limitations survey conducted metropolitan chicago height first wave covid19 pandemic may generalizable areas time frames responses collected caregivers able receive sms messages email requests participate response rates low response bias possible respondents similar nonrespondents terms child sex age categories coi distribution addresses listed emr may outdated could result misclassification bias coi communitylevel covid19 rates finally hypothetical scenario may brought different emergency conditions mind caregiver responses may translate careseeking behaviors faced emergency results define hesitancy seek emergency care among caregivers children greater hesitancy within vulnerable populations could exacerbate health disparities covid19 pandemic health systems health plans monitor acute care utilization intervene caregivers ensure children receiving necessary timely care emergency conditions authors potential conflicts disclose michelle l macy contributed study concept design analysis interpretation data drafting manuscript critical revisions manuscript important intellectual content tracie l smith jenifer cartland contributed study concept design analysis interpretation data statistical expertise critical revisions manuscript important intellectual content emily golbeck contributed study concept design acquisition data critical revisions manuscript important intellectual content matthew davis contributed study concept design analysis interpretation data critical revisions manuscript important intellectual content